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KROGER PHARMACY J918
DSH140067 SAINT FRANCIS MEDICAL CENTER
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Covered Entity Details
Entity Name
SAINT FRANCIS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140067
Entity Address
530 NE GLEN OAK AVENUE
PEORIA, IL 61637
Medicare Provider Number
140067
Participating Start Date
10/1/2006
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY J918
Pharmacy Address
9219 N LINDBERGH DR
PEORIA, IL 61615
Pharmacy Comments
Contract Details
Approval Date
4/5/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KEVIN D. SCHOEPLEIN, CEO
(309) 655-2850
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/5/2013
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