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KROGER PHARMACY L411
CAH181301-00 Marcum & Wallace Memorial Hospital
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Covered Entity Details
Entity Name
Marcum & Wallace Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181301-00
Entity Address
60 Mercy Ct
Irvine, KY 40336
Medicare Provider Number
181301
Participating Start Date
7/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY L411
Pharmacy Address
179 WEST COLLEGE AVENUE
STANTON, KY 40380
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Witt, CFO
(606) 726-6507
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/16/2015
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