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KROGER PHARMACY
CH05320AF HealthNet, Inc.
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Covered Entity Details
Entity Name
HealthNet, Inc.
Subdivision Name
KIPP Indy Legacy Clinic
Type
HRSA-Funded Health Center
340B ID
CH05320AF
Entity Address
2255 Ralston Ave Rm 106
Rm 106
Indianapolis, IN 46218-3444
Grant Number
H80CS00114
Participating Start Date
1/1/2020
Last Recertification Date
2/3/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
KROGER PHARMACY
Pharmacy Address
#116
680 TWIN AIRE DRIVE
INDIANAPOLIS, IN 46203
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Varon Edward Cantrell, Chief Medical Officer
(317) 957-2015
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/13/2023
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