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KROGER DRUG STORE #469
DSH440152 Regional One Health
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Covered Entity Details
Entity Name
Regional One Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440152
Entity Address
877 JEFFERSON AVENUE
MEMPHIS, TN 38103
Medicare Provider Number
440152
Participating Start Date
4/1/1993
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER DRUG STORE #469
Pharmacy Address
11877 DOUGLAS ROAD
ALPHARETTA, GA 30005
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rick Wagers, CFO
(901) 545-7676
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/8/2020
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