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KROGER FOOD AND DRUG 430
DSH440152 Regional One Health
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Covered Entity Details
Entity Name
Regional One Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440152
Entity Address
877 JEFFERSON AVENUE
MEMPHIS, TN 38103
Medicare Provider Number
440152
Participating Start Date
4/1/1993
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER FOOD AND DRUG 430
Pharmacy Address
540 S MENDENHALL RD, STE 16
MEMPHIS, TN 38117-4200
Pharmacy Comments
Contract Details
Approval Date
10/11/2012
Contract Begin Date
10/11/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rick Wagers, CFO
(901) 545-7676
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/14/2012
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