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KROGER PHARMACY #675
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #675
Pharmacy Address
1795 WHISKEY ROAD
AIKEN, SC 29803
Pharmacy Comments
Contract Details
Approval Date
10/19/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Allen R Butcher, CFO
(706) 721-3929
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/19/2021
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