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KROGER PHARMACY #427
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.
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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 PHARMACY #427
Pharmacy Address
9155 MANSFIELD ROAD
SHREVEPORT, LA 71118
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
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