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KROGER DRUGSTORE #609
DSH110024 CANDLER HOSPITAL
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Covered Entity Details
Entity Name
CANDLER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110024
Entity Address
5353 REYNOLDS STREET
SAVANNAH, GA 31405
Medicare Provider Number
110024
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
KROGER DRUGSTORE #609
Pharmacy Address
495 JOHNNY MERCER BLVD
SAVANNAH, GA 31410
Pharmacy Comments
Contract Details
Approval Date
12/17/2012
Contract Begin Date
12/17/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/13/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PAUL P. HINCHEY, CEO
(912) 819-6901
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/18/2012
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