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THE KROGER CO
RRC140034-00 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
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Covered Entity Details
Entity Name
ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140034-00
Entity Address
400 NORTH PLEASANT AVENUE
CENTRALIA, IL 62801
Medicare Provider Number
140034
Participating Start Date
4/1/2011
Last Recertification Date
9/19/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
THE KROGER CO
Pharmacy Address
415 S 42ND ST
MOUNT VERNON, IL 62864
Pharmacy Comments
Contract Details
Approval Date
7/10/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Damon Harbison, President
(618) 436-8000
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/10/2020
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