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KROGER PHARMACY #722
DSH510038 STONEWALL JACKSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
STONEWALL JACKSON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510038
Entity Address
230 Hospital Plaza
WESTON, WV 26452
Medicare Provider Number
510038
Participating Start Date
1/1/2019
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #722
Pharmacy Address
80 SKYLINE PLAZA DR
BUCKHANNON, WV 26201
Pharmacy Comments
Contract Details
Approval Date
9/7/2011
Contract Begin Date
9/7/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dodie Arbogast, Controller
(304) 269-8050
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
8/12/2011
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