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KROGER PHARMACY #642
DSH040072 BAPTIST HEALTH MEDICAL CENTER - STUTTGART
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - STUTTGART
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040072
Entity Address
1703 NORTH BUERKLE
STUTTGART, AR 72160
Medicare Provider Number
040072
Participating Start Date
1/1/2011
Last Recertification Date
9/18/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #642
Pharmacy Address
6929 J F K BOULEVARD
NORTH LITTLE ROCK, AR 72116
Pharmacy Comments
Contract Details
Approval Date
7/7/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/28/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/7/2021
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