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KROGER PHARMACY #394
DSH190013 WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190013
Entity Address
701 EAST CYPRESS
SULPHUR, LA 70663
Medicare Provider Number
190013
Participating Start Date
10/1/2018
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #394
Pharmacy Address
2010 COUNTRY CLUB RD
LAKE CHARLES, LA 70605
Pharmacy Comments
Contract Details
Approval Date
4/8/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jobie James, Chief Financial Officer
(337) 527-4143
Contract Pharmacy Representative
Kroger
Katie Elfers, 340B Pharmacy Administrator
(513) 762-4850
Signed By Date
4/8/2022
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