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THE KROGER CO OF MICHIGAN 464
RRC230130-00 WILLIAM BEAUMONT HOSPITAL dba Beaumont Hospital - Royal Oak
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Covered Entity Details
Entity Name
WILLIAM BEAUMONT HOSPITAL dba Beaumont Hospital - Royal Oak
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230130-00
Entity Address
3601 WEST 13 MILE ROAD
ROYAL OAK, MI 48073-6769
Medicare Provider Number
230130
Participating Start Date
4/1/2017
Last Recertification Date
8/30/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
THE KROGER CO OF MICHIGAN 464
Pharmacy Address
2105 SOUTH BLVD. W
TROY, MI 48098
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Carolyn Wilson, Chief Operating Officer
(947) 522-3338
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/12/2021
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