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KROGER PHARMACY
DSH510022AA CHARLESTON AREA MEDICAL CENTER (CAMC)
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Covered Entity Details
Entity Name
CHARLESTON AREA MEDICAL CENTER (CAMC)
Subdivision Name
CAMC Memorial Nuclear Medicine
Type
Disproportionate Share Hospital
340B ID
DSH510022AA
Entity Address
3200 MacCorkle Avenue SE
Charleston, WV 25304
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
Pharmacy Address
500 DELAWARE AVE
CHARLESTON, WV 25302
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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