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KROGER PHARMACY #465
DSH040069 GREAT RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
GREAT RIVER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040069
Entity Address
1520 NORTH DIVISION ST
BLYTHEVILLE, AR 72315
Medicare Provider Number
040069
Participating Start Date
4/1/2020
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #465
Pharmacy Address
400 WEST MOULTRIE
BLYTHEVILLE, AR 72315
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Raymer, CEO
(870) 838-7463
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/14/2022
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