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KROGER PHARMACY #747
DSH190013A WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
ENT ASSOC W CALCASIEU CAMERON HOSPI - ENT Associates of West Calcasieu Cameron Hospital
Type
Disproportionate Share Hospital
340B ID
DSH190013A
Entity Address
1629 Beglis Parkway
SULPHUR, LA 70663-5641
Medicare Provider Number
190013
Outpatient Facility Provider Number
Participating Start Date
10/1/2018
Last Recertification Date
9/4/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #747
Pharmacy Address
1421 BEGLIS PKWY
SULPHUR, LA 70663-5603
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jobie James, Chief Financial Officer
(337) 527-4143
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/14/2019
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