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KROGER PHARMACY #743
DSH230130 Corewell Health William Beaumont University Hospital
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Covered Entity Details
Entity Name
Corewell Health William Beaumont University Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230130
Entity Address
3601 WEST 13 MILE ROAD
ROYAL OAK, MI 48073-6769
Medicare Provider Number
230130
Participating Start Date
4/1/2024
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #743
Pharmacy Address
2200 EAST 12 MILE RD
ROYAL OAK, MI 48067
Pharmacy Comments
Contract Details
Approval Date
1/31/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Hardik Dalal, SVP, Finance & System-wide Pharmacy Finance
(312) 771-0810
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/16/2024
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