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THE KROGER CO., KS 113
CAH171334-00 Medicine Lodge Memorial Hospital
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Covered Entity Details
Entity Name
Medicine Lodge Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171334-00
Entity Address
710 N. Walnut
Medicine Lodge, KS 67104
Medicare Provider Number
171334
Participating Start Date
7/1/2013
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
THE KROGER CO., KS 113
Pharmacy Address
1220 S. LIPAN STREET
DENVER, CO 80223
Pharmacy Comments
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/16/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jennifer Bowe, CFO
(620) 930-3702
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/18/2016
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