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KROGER PHARMACY L - 594
DSH440073 MAURY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MAURY REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440073
Entity Address
1224 TROTWOOD AVENUE
COLUMBIA, TN 38401
Medicare Provider Number
440073
Participating Start Date
7/20/2022
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L - 594
Pharmacy Address
4900 PORT ROYAL ROAD
SPRINGHILL, TN 37174
Pharmacy Comments
Contract Details
Approval Date
9/29/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Martin Chaney, Chief Executive Officer
(931) 380-4008
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
9/29/2022
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