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KROGER PHARMACY
DSH490024 CARILION MEDICAL CENTER
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Covered Entity Details
Entity Name
CARILION MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490024
Entity Address
1906 BELLEVIEW AVE SE
ROANOKE, VA 24014
Medicare Provider Number
490024
Participating Start Date
10/1/2007
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY
Pharmacy Address
240 W COMMONWEALTH BLVD
MARTINSVILLE, VA 24112
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
10/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Auwarter, VP Hospital Operations
(540) 981-7804
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/14/2019
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