Contract Pharmacy Details

KROGER PHARMACY #490
DSH450475 East Texas Medical Center Henderson

Covered Entity Details

Entity Name

East Texas Medical Center Henderson

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH450475

Entity Address

300 WILSON STREET
HENDERSON, TX 75652

Medicare Provider Number

450475

Participating Start Date

1/1/2008

Last Recertification Date

11/9/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

KROGER PHARMACY #490

Pharmacy Address

2415 HIGHWAY 79 S
HENDERSON, TX 75654

Pharmacy Comments

Contract Details

Approval Date

7/2/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

MARK LEITNER, CEO
(903) 655-3616

Contract Pharmacy Representative

Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672

Signed By Date

7/2/2014

340B Drug Pricing Program Database