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KING SOOPERS PHARMACY
DSH060012 St. Mary-Corwin Hospital
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Covered Entity Details
Entity Name
St. Mary-Corwin Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060012
Entity Address
1008 Minnequa Avenue
Pueblo, CO 81004
Medicare Provider Number
060012
Participating Start Date
4/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KING SOOPERS PHARMACY
Pharmacy Address
#12
3050 W NORTHERN AVE
PUEBLO, CO 81005-2317
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Cafasso, Chief Executive Officer
(719) 557-4678
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/7/2020
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