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KROGER DRUGSTORE #425
DSH110107 Atrium Health Navicent The Medical Center
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Covered Entity Details
Entity Name
Atrium Health Navicent The Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110107
Entity Address
777 HEMLOCK ST.
MACON, GA 31201-2102
Medicare Provider Number
110107
Participating Start Date
12/1/1992
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
KROGER DRUGSTORE #425
Pharmacy Address
5928 ZEBULON ROAD
MACON, GA 31210
Pharmacy Comments
Contract Details
Approval Date
3/14/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rhonda Perry, CFO
(478) 633-1440
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/31/2013
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