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KROGER PHARMACY #16977
RRC510039-00 Ohio Valley Medical Center, Incorporated
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Covered Entity Details
Entity Name
Ohio Valley Medical Center, Incorporated
Subdivision Name
Type
Rural Referral Center
340B ID
RRC510039-00
Entity Address
2000 Eoff Street
Wheeling, WV 26003
Medicare Provider Number
510039
Participating Start Date
7/1/2013
Last Recertification Date
8/13/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #16977
Pharmacy Address
1300 LAFAYETTE AVENUE
MOUNDSVILLE, WV 26041
Pharmacy Comments
Contract Details
Approval Date
1/19/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lisa M. Simon, Senior Vice President & CFO
(304) 234-8407
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/19/2015
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