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KROGER PHARMACY
RRC140046-00 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
KROGER PHARMACY
Pharmacy Address
1704 WEST DEYOUNG STREET
MARION, IL 62959
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
10/23/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeremy Shawn Bradford, President
(618) 899-1002
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/10/2020
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