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KROGER PHARMACY #16977
DSH510039 OHIO VALLEY MEDICAL CENTER, INCORPORATED
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Covered Entity Details
Entity Name
OHIO VALLEY MEDICAL CENTER, INCORPORATED
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510039
Entity Address
2000 EOFF STREET
WHEELING, WV 26003
Medicare Provider Number
510039
Participating Start Date
4/1/2016
Last Recertification Date
8/15/2016
Entity Termination Date
7/1/2017
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #16977
Pharmacy Address
1300 LAFAYETTE AVENUE
MOUNDSVILLE, WV 26041
Pharmacy Comments
Contract Details
Approval Date
3/24/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Contacts
Covered Entity Signing Official
Lisa M. Simon, Senior Vice President & CFO
(304) 234-8407
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
3/24/2016
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