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KROGER PHARMACY #491
DSH440049 METHODIST HEALTHCARE - MEMPHIS HOSPITALS
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Covered Entity Details
Entity Name
METHODIST HEALTHCARE - MEMPHIS HOSPITALS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440049
Entity Address
1265 Union Ave
Memphis, TN 38104
Medicare Provider Number
440049
Participating Start Date
7/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #491
Pharmacy Address
799 TRUSE PKWY
MEMPHIS, TN 38117
Pharmacy Comments
Contract Details
Approval Date
10/6/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/18/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHRIS MCLEAN, SENIOR VP/CFO
(901) 516-0753
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/6/2015
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