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KROGER PHARMACY #730
DSH510030 Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
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Covered Entity Details
Entity Name
Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510030
Entity Address
812 Gorman Avenue
ELKINS, WV 26241
Medicare Provider Number
510030
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #730
Pharmacy Address
450-11TH ST
ELKINS, WV 26241
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
REBECCA J. HAMMER, VICE PRESIDENT FOR FINANCE
(304) 637-3156
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/15/2013
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