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KROGER PHARMACY L-900
DSH180149 TJ HEALTH COLUMBIA
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Covered Entity Details
Entity Name
TJ HEALTH COLUMBIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180149
Entity Address
901 Wellness Way
COLUMBIA, KY 42728
Medicare Provider Number
180149
Participating Start Date
4/1/2019
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L-900
Pharmacy Address
181 SOUTH HIGHWAY 127
RUSSELL SPRINGS, KY 42642
Pharmacy Comments
Contract Details
Approval Date
9/19/2011
Contract Begin Date
9/21/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
TIMOTHY MENTON, INTERIM CEO
(270) 374-4753
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/13/2011
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