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KROGER PHARMACY #688
DSH510006 UNITED HOSPITAL CENTER
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Covered Entity Details
Entity Name
UNITED HOSPITAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510006
Entity Address
327 MEDICAL PARK DRIVE
BRIDGEPORT, WV 26330
Medicare Provider Number
510006
Participating Start Date
10/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #688
Pharmacy Address
788 WEST PIKE STREET
CLARKSBURG, WV 26301
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
James Rutkowski, VP Finance/CFO
(681) 342-1605
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/15/2020
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