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THE KROGER PHARMACY #858
FQHCLA275 FAMILY HEALTH SERVICES OF ERIE COUNTY
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Covered Entity Details
Entity Name
FAMILY HEALTH SERVICES OF ERIE COUNTY
Subdivision Name
Type
Health Center Program Look-Alike
340B ID
FQHCLA275
Entity Address
1912 HAYES AVENUE
SANDUSKY, OH 44870
Grant Number
LALCS00098
Participating Start Date
4/1/2011
Last Recertification Date
2/16/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
THE KROGER PHARMACY #858
Pharmacy Address
226 E. PERKINS AVE
SANDUSKY, OH 44870
Pharmacy Comments
Contract Details
Approval Date
10/12/2011
Contract Begin Date
10/19/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Wilson Forney, Chief Executive Officer
(419) 502-2818
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/12/2011
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