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KROGER PHARMACY L672
DSH140164 MEMORIAL HOSPITAL OF CARBONDALE
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF CARBONDALE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140164
Entity Address
405 WEST JACKSON STREET
CARBONDALE, IL 62901
Medicare Provider Number
140164
Participating Start Date
1/1/2009
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L672
Pharmacy Address
45 PLAZA DR
ANNA, IL 62906-2034
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/23/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
REX BUDDE, CEO
(618) 457-5200
Contract Pharmacy Representative
Kroger
Katie Elfers, 340B Pharmacy Administrator
(513) 762-4850
Signed By Date
4/14/2022
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