Contract Pharmacy Details

KROGER PHARMACY #427
DSH190041A CHRISTUS Health Shreveport-Bossier

Covered Entity Details

Entity Name

CHRISTUS Health Shreveport-Bossier

Subdivision Name

CHRISTUS Highland Medical Center

Type

Disproportionate Share Hospital

340B ID

DSH190041A

Entity Address

1453 E BERT KOUNS INDUSTRIAL LOOP
SHREVEPORT, LA 71105

Medicare Provider Number

190041

Outpatient Facility Provider Number

Participating Start Date

4/1/2006

Last Recertification Date

8/24/2015

Entity Termination Date

7/1/2016

Pharmacy Details

Pharmacy Name

KROGER PHARMACY #427

Pharmacy Address

9155 MANSFIELD ROAD
SHREVEPORT, LA 71118

Pharmacy Comments

Contract Details

Approval Date

2/21/2012

Contract Begin Date

2/21/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2016

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

2/14/2012

340B Drug Pricing Program Database