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KROGER PHARMACY #425
DSH150021 Parkview Hospital
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Covered Entity Details
Entity Name
Parkview Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150021
Entity Address
11109 PARKVIEW PLAZA DRIVE
FORT WAYNE, IN 46845
Medicare Provider Number
150021
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #425
Pharmacy Address
6310 E STATE BLVD
FORT WAYNE, IN 46815-7023
Pharmacy Comments
Contract Details
Approval Date
4/19/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stanton Risser, Assoc Chief Financial Officer
(260) 266-9313
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/19/2016
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