Contract Pharmacy Details

KROGER FOOD AND DRUG
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.

Covered Entity Details

Entity Name

WILLIS KNIGHTON MEDICAL CENTER, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH190111

Entity Address

2600 GREENWOOD ROAD
SHREVEPORT, LA 71103

Medicare Provider Number

190111

Participating Start Date

1/1/2007

Last Recertification Date

8/17/2024

Pharmacy Details

Pharmacy Name

KROGER FOOD AND DRUG

Pharmacy Address

6652 YOUREE
SHREVEPORT, LA 71105

Pharmacy Comments

Contract Details

Approval Date

4/14/2015

Contract Begin Date

7/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/10/2025
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Charles D. Daigle, COO
(318) 212-4292

Contract Pharmacy Representative

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

Signed By Date

4/14/2015

340B Drug Pricing Program Database