340B Drug Pricing Program Database
PALACE DRUG
CAH371320-00 CLEVELAND AREA HOSPITAL - information as of 5/20/2025 11:57:22 PM
Covered Entity Details
Entity Name
CLEVELAND AREA HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371320-00
Entity Address
1401 W PAWNEE
CLEVELAND, OK 74020
Medicare Provider Number
371320
Participating Start Date
1/1/2022
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
PALACE DRUG
Pharmacy Address
MOORE HEALTH CARE
301 N BROADWAY ST
CLEVELAND, OK 74020-3421
Pharmacy Comments
Contract Details
Approval Date
4/14/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melva D. Bostik, RN, BSN, RHCNOC
(918) 358-2501 Ext: 4326
Contract Pharmacy Representative
Palace Drug Store
Kim Tilley, Owner
(918) 358-2524
Signed By Date
4/14/2025
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