Contract Pharmacy Details

KROGER PHARMACY L-355
DSH180021 PINEVILLE COMMUNITY HOSPITAL ASSOC., INC.

Covered Entity Details

Entity Name

PINEVILLE COMMUNITY HOSPITAL ASSOC., INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH180021

Entity Address

850 RIVERVIEW AVENUE
PINEVILLE, KY 40977

Medicare Provider Number

180021

Participating Start Date

4/1/2006

Last Recertification Date

9/8/2016

Entity Termination Date

10/1/2016

Pharmacy Details

Pharmacy Name

KROGER PHARMACY L-355

Pharmacy Address

515 N 12TH STREET
MIDDLESBORO, KY 40965

Pharmacy Comments

Contract Details

Approval Date

4/26/2012

Contract Begin Date

5/4/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/29/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Colan Kelly, CFO
(606) 337-3051

Contract Pharmacy Representative

Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672

Signed By Date

4/27/2012

340B Drug Pricing Program Database