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KROGER PHARMACY
CAH151313-00 WOODLAWN HOSPITAL
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Covered Entity Details
Entity Name
WOODLAWN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151313-00
Entity Address
1400 EAST 9TH STREET
ROCHESTER, IN 46975
Medicare Provider Number
151313
Participating Start Date
1/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY
Pharmacy Address
#902
930 W MAIN STREET
PERU, IN 46970
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carl John Kraft, Vice Pesident
(574) 224-1118
Contract Pharmacy Representative
Woodlawn Hospital
Terry Ayers, Director of Pharmacy
(574) 224-1440
Signed By Date
1/15/2020
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