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KROGER PHARMACY L-893
RRC440059-00 COOKEVILLE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COOKEVILLE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC440059-00
Entity Address
142 WEST FIFTH STREET
COOKEVILLE, TN 38501
Medicare Provider Number
440059
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L-893
Pharmacy Address
445 SOUTH JEFFERSON AVENUE
COOKEVILLE, TN 38501
Pharmacy Comments
Contract Details
Approval Date
6/11/2012
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
PAUL Dudley KORTH, CEO
(931) 783-2000
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
5/31/2012
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