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BAKER'S PHARMACY # 300
DSH280060 Alegent Health Bergan Mercy Health System d/b/a CHI Health Creighton University Med Center-Bergan Mercy
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Covered Entity Details
Entity Name
Alegent Health Bergan Mercy Health System d/b/a CHI Health Creighton University Med Center-Bergan Mercy
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH280060
Entity Address
7500 Mercy Road
Omaha, NE 68124
Medicare Provider Number
280060
Participating Start Date
1/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
BAKER'S PHARMACY # 300
Pharmacy Address
3614 TWIN CREEK DRIVE
BELLEVUE, NE 68123
Pharmacy Comments
Contract Details
Approval Date
7/7/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/23/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jayleen Joy Casano, CEO/President
(402) 398-6020
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/7/2020
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