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SMITH'S FOOD & DRUG CTRS
SCH030055-00 Kingman Regional Medical Center
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Covered Entity Details
Entity Name
Kingman Regional Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030055-00
Entity Address
3269 Stockton Hill Road
Kingman, AZ 86409
Medicare Provider Number
030055
Participating Start Date
7/1/2013
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
SMITH'S FOOD & DRUG CTRS
Pharmacy Address
SMITHS PHARMACY #0190
3490 STOCKTON HILL RD
KINGMAN, AZ 86409
Pharmacy Comments
11/25/2011 updated zip (was 86409);12/23/2011 changed zip back to previous (was 86401)
Contract Details
Approval Date
7/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Blanchard, CFO
(928) 681-8668
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/1/2013
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