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KROGER PHARMACY #984
DSH360174 UPPER VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
UPPER VALLEY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360174
Entity Address
3130 N. COUNTY ROAD 25 A
TROY, OH 45373
Medicare Provider Number
360174
Participating Start Date
1/1/2016
Last Recertification Date
11/29/2017
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #984
Pharmacy Address
731 WEST MARKET STREET
TROY, OH 45373
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Timothy Snider, VP Finance
(937) 440-4558
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
10/15/2015
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