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KROGER #763
DSH510029 Thomas Memorial Hospital
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Covered Entity Details
Entity Name
Thomas Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510029
Entity Address
4605 MacCorkle Avenue, SW
South Charleston, WV 25309
Medicare Provider Number
510029
Participating Start Date
7/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
KROGER #763
Pharmacy Address
5450 BIG TYLER ROAD
CROSS LANES, WV 25313
Pharmacy Comments
Contract Details
Approval Date
10/7/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dan Lauffer, Chief Operating Officer
(304) 766-3595
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/7/2014
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