Contract Pharmacy Details

KROGER DRUGSTORE #436
DSH110018 PIEDMONT NEWTON HOSPITAL, INC.

Covered Entity Details

Entity Name

PIEDMONT NEWTON HOSPITAL, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110018

Entity Address

5126 HOSPITAL DRIVE
COVINGTON, GA 30014

Medicare Provider Number

110018

Participating Start Date

1/1/2011

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

KROGER DRUGSTORE #436

Pharmacy Address

5341 HWY 20, SOUTH
COVINGTON, GA 30016

Pharmacy Comments

Contract Details

Approval Date

12/28/2011

Contract Begin Date

12/28/2011

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/23/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

TROY B. BROOKS, CFO
(770) 385-4426

Contract Pharmacy Representative

Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672

Signed By Date

12/19/2011

340B Drug Pricing Program Database