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KROGER PHARMACY#799
RRC510058-00 Camden-Clark Memorial Hospital Corporation d/b/a Camden Clark Medical Center
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Covered Entity Details
Entity Name
Camden-Clark Memorial Hospital Corporation d/b/a Camden Clark Medical Center
Subdivision Name
Type
Rural Referral Center
340B ID
RRC510058-00
Entity Address
800 Garfield Avenue
Parkersburg, WV 26101
Medicare Provider Number
510058
Participating Start Date
4/1/2014
Last Recertification Date
9/3/2014
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
KROGER PHARMACY#799
Pharmacy Address
1008 WASHINGTON BLVD
BELPRE, OH 45714
Pharmacy Comments
Contract Details
Approval Date
4/3/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David K. McClure, President/CEO
(304) 424-2204
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/3/2015
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