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KROGER PHARMACY #014827
DSH150064 FAYETTE MEMORIAL HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
FAYETTE MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150064
Entity Address
1941 VIRGINIA AVENUE
CONNERSVILLE, IN 47331
Medicare Provider Number
150064
Participating Start Date
4/1/2010
Last Recertification Date
9/4/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #014827
Pharmacy Address
516 WEST 30TH STREET
CONNERSVILLE, IN 47331
Pharmacy Comments
Contract Details
Approval Date
10/25/2012
Contract Begin Date
10/25/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Skip Smith, CFO
(765) 817-7989
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/25/2012
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