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KROGER PHARMACY L522
DSH180051 JENNIE STUART MEDICAL CENTER
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Covered Entity Details
Entity Name
JENNIE STUART MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180051
Entity Address
320 WEST 18TH STREET
HOPKINSVILLE, KY 42240
Medicare Provider Number
180051
Participating Start Date
9/2/2008
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L522
Pharmacy Address
1213 SKYLINE DRIVE
HOPKINSVILLE, KY 42240
Pharmacy Comments
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/4/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim Bishop, Controller
(270) 887-0251
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/15/2014
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