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KROGER PHARMACY #768
DSH510022AM CHARLESTON AREA MEDICAL CENTER (CAMC)
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Covered Entity Details
Entity Name
CHARLESTON AREA MEDICAL CENTER (CAMC)
Subdivision Name
Women & Childrens Recovery Room
Type
Disproportionate Share Hospital
340B ID
DSH510022AM
Entity Address
800 Pennsylvania Avenue
Charleston, WV 25302
Medicare Provider Number
510022
Outpatient Facility Provider Number
Participating Start Date
10/1/2012
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #768
Pharmacy Address
981 DUNBAR VILLAGE
DUNBAR, WV 25064
Pharmacy Comments
Contract Details
Approval Date
1/14/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/20/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
LARRY HUDSON, EXECUTIVE VICE PRESIDENT AND CFO
(304) 388-7603
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/14/2016
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