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KROGER PHARMACY#799
DSH510058 CAMDEN-CLARK MEMORIAL HOSP
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Covered Entity Details
Entity Name
CAMDEN-CLARK MEMORIAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510058
Entity Address
800 GARFIELD AVENUE
PARKERSBURG, WV 26101
Medicare Provider Number
510058
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY#799
Pharmacy Address
1008 WASHINGTON BLVD
BELPRE, OH 45714
Pharmacy Comments
Contract Details
Approval Date
8/10/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Business decision by covered entity and/or pharmacy
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
8/10/2015
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