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KROGER SAV-ON PHCY #724
CAH261319-00 Mercy Hospital Lincoln
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Covered Entity Details
Entity Name
Mercy Hospital Lincoln
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261319-00
Entity Address
1000 E CHERRY ST
TROY, MO 63379
Medicare Provider Number
261319
Participating Start Date
8/24/2010
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
KROGER SAV-ON PHCY #724
Pharmacy Address
#1 TROY SQUARE
TROY, MO 63379
Pharmacy Comments
Contract Details
Approval Date
10/20/2011
Contract Begin Date
10/11/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/26/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patrick Bira, CEO
(636) 528-3324
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
9/27/2011
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