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KROGER DRUGSTORE #393
DSH440104 Erlanger Health
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Covered Entity Details
Entity Name
Erlanger Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440104
Entity Address
975 East Third Street
CHATTANOOGA, TN 37403
Medicare Provider Number
440104
Participating Start Date
12/1/1992
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
KROGER DRUGSTORE #393
Pharmacy Address
136 WEST BELMONT DRIVE, SW
CALHOUN, GA 30701
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
7/28/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
BRITTON J. TABOR, CFO
(423) 778-7729
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/15/2020
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