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KROGER PHARMACY #696
DSH110069 HOUSTON MEDICAL CENTER
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Covered Entity Details
Entity Name
HOUSTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110069
Entity Address
1601 WATSON BLVD
WARNER ROBINS, GA 31093
Medicare Provider Number
110069
Participating Start Date
7/1/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #696
Pharmacy Address
3094 WATSON BLVD
WARNER ROBINS, GA 31088
Pharmacy Comments
Contract Details
Approval Date
4/13/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sean Whilden, Vice-President/Chief Financial Officer
(478) 542-7959
Contract Pharmacy Representative
Kroger
Katie Elfers, 340B Pharmacy Administrator
(513) 762-4850
Signed By Date
4/13/2022
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