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KROGER PHARMACY #781
DSH180009 KING'S DAUGHTERS MEDICAL CENTER
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Covered Entity Details
Entity Name
KING'S DAUGHTERS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180009
Entity Address
2201 LEXINGTON AVENUE
ASHLAND, KY 41101
Medicare Provider Number
180009
Participating Start Date
4/1/2006
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #781
Pharmacy Address
6306 COUNTY ROAD 107
PROCTORVILLE, OH 45669
Pharmacy Comments
Contract Details
Approval Date
9/14/2012
Contract Begin Date
9/14/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul McDowell, CFO
(606) 408-4404
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
8/28/2012
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