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KROGER PHARMACY #268
RRC510023-00 WEIRTON MEDICAL CENTER
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Covered Entity Details
Entity Name
WEIRTON MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC510023-00
Entity Address
601 COLLIERS WAY
WEIRTON, WV 26062
Medicare Provider Number
510023
Participating Start Date
1/1/2021
Last Recertification Date
8/31/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #268
Pharmacy Address
91-27TH STREET
WELLSBURG, WV 26070
Pharmacy Comments
Contract Details
Approval Date
10/8/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eugene D Trout, CFO
(304) 797-6323
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/8/2019
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