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KROGER PHARMACY 901
DSH360054 HOLZER
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Covered Entity Details
Entity Name
HOLZER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360054
Entity Address
100 JACKSON PIKE
GALLIPOLIS, OH 45631
Medicare Provider Number
360054
Participating Start Date
7/1/2006
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY 901
Pharmacy Address
919 E. STATE ST.
ATHENS, OH 45701
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jerel T. Humphrey, EVP - Acute Care Services
(740) 446-5021
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/17/2017
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