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KROGER PHARMACY 014920
CAH361326-01 ADAMS COUNTY HOSPITAL DBA ADAMS COUNTY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ADAMS COUNTY HOSPITAL DBA ADAMS COUNTY REGIONAL MEDICAL CENTER
Subdivision Name
Family Medicine Georgetown - Family Medicine
Type
Critical Access Hospital
340B ID
CAH361326-01
Entity Address
900 Mt Orab Pike
Georgetown, OH 45121
Medicare Provider Number
361326
Outpatient Facility Provider Number
363418
Participating Start Date
10/1/2020
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY 014920
Pharmacy Address
210 STERLING RUN BLVD.
MT. ORAB, OH 45154
Pharmacy Comments
Contract Details
Approval Date
10/5/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Pete R Dagenbach, CFO
(937) 386-3007
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/5/2020
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