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KROGER PHARMACY #014817
DSH360051 MIAMI VALLEY HOSPITAL
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Covered Entity Details
Entity Name
MIAMI VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360051
Entity Address
ONE WYOMING STREET
DAYTON, OH 45409
Medicare Provider Number
360051
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #014817
Pharmacy Address
1230 ROMBACH AVENUE
WILMINGTON, OH 45177
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Scott Andrew Shelton, VP CFO
(937) 499-9989
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/8/2020
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