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KROGER PHARMACY L-901
CAH181321-00 Wayne County Hospital, Inc.
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Covered Entity Details
Entity Name
Wayne County Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181321-00
Entity Address
166 Hospital Street
Monticello, KY 42633
Medicare Provider Number
181321
Participating Start Date
4/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L-901
Pharmacy Address
255 CUMBERLAND CROSSING
MONTICELLO, KY 42633
Pharmacy Comments
Contract Details
Approval Date
8/29/2012
Contract Begin Date
8/29/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/29/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Anne Sawyer, CFO
(606) 348-9343
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
8/21/2012
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