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KROGER PHARMACY #629
DSH040114 BAPTIST HEALTH MEDICAL CENTER - LR
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - LR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040114
Entity Address
9601 Baptist Health Drive
LITTLE ROCK, AR 72205
Medicare Provider Number
040114
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #629
Pharmacy Address
20820 I-30 NORTH
BENTON, AR 72019
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Kroger Health
Eva Brumfield, Strategic Program Director
(651) 357-2109
Signed By Date
4/12/2023
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