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KROGER PHARMACY #16664
DSH360008 SOUTHERN OHIO MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHERN OHIO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360008
Entity Address
1805 27TH STREET
PORTSMOUTH, OH 45662
Medicare Provider Number
360008
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #16664
Pharmacy Address
9101 OHIO RIVER ROAD
WHEELERSBURG, OH 45694
Pharmacy Comments
Contract Details
Approval Date
4/13/2011
Contract Begin Date
4/15/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
4/11/2011
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