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KROGER PHARMACY #774
DSH230165 Ascension St. John Hospital DBA Henry Ford St. John Hospital
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Covered Entity Details
Entity Name
Ascension St. John Hospital DBA Henry Ford St. John Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230165
Entity Address
22101 MOROSS ROAD
DETROIT, MI 48236
Medicare Provider Number
230165
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #774
Pharmacy Address
20891 E 13 MILE RD
ROSEVILLE, MI 48066
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Douglas Winner, CFO, Acute Care Operations
(586) 753-0662
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
4/14/2020
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