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KROGER PHARMACY #637
DSH040114 BAPTIST HEALTH MEDICAL CENTER - LR
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Covered Entity Details
Entity Name
BAPTIST HEALTH MEDICAL CENTER - LR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040114
Entity Address
9601 Baptist Health Drive
LITTLE ROCK, AR 72205
Medicare Provider Number
040114
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #637
Pharmacy Address
1410 MILITARY ROAD
BENTON, AR 72015
Pharmacy Comments
Contract Details
Approval Date
1/18/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/18/2017
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