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KROGER PHARMACY #747
DSH190013C WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
Hackberry Rural Health Clinic - Hackberry Rural Health Clinic
Type
Disproportionate Share Hospital
340B ID
DSH190013C
Entity Address
1020 Main St,
Hackberry, LA 70645
Medicare Provider Number
190013
Outpatient Facility Provider Number
193997
Participating Start Date
10/1/2018
Last Recertification Date
8/27/2024
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
6/19/2023
Business decision by covered entity and/or pharmacy
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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