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KROGER PHARMACY #427
DSH190041 CHRISTUS Shreveport-Bossier Health System
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Covered Entity Details
Entity Name
CHRISTUS Shreveport-Bossier Health System
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190041
Entity Address
1453 E. Bert Kouns Industrial Loop
Shreveport, LA 71105
Medicare Provider Number
190041
Participating Start Date
7/1/2024
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #427
Pharmacy Address
9155 MANSFIELD ROAD
SHREVEPORT, LA 71118
Pharmacy Comments
Contract Details
Approval Date
4/10/2012
Contract Begin Date
4/10/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Contacts
Covered Entity Signing Official
Scott Merryman, EVP/CFO
(318) 561-7172
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
3/27/2012
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