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KROGER PHARMACY #330
DSH150051 IU HEALTH BLOOMINGTON HOSPITAL
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Covered Entity Details
Entity Name
IU HEALTH BLOOMINGTON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150051
Entity Address
2651 EAST DISCOVERY PARKWAY
BLOOMINGTON, IN 47408
Medicare Provider Number
150051
Participating Start Date
10/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #330
Pharmacy Address
1825 N KINSER PIKE
BLOOMINGTON, IN 47404
Pharmacy Comments
Contract Details
Approval Date
1/13/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jennifer M. Alvey, SVP & CFO
(317) 963-0213
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/13/2021
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