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PALACE DRUG STORE
CAH371319-00 COAL COUNTY
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Covered Entity Details
Entity Name
COAL COUNTY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371319-00
Entity Address
6 NORTH COVINGTON
COALGATE, OK 74538
Medicare Provider Number
371319
Participating Start Date
4/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
PALACE DRUG STORE
Pharmacy Address
104 W OHIO AVE
PO BOX 273
COALGATE, OK 74538
Pharmacy Comments
Contract Details
Approval Date
4/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Billy D Johnson, Chief Executive Officer
(580) 927-2327 Ext: 272
Contract Pharmacy Representative
Palace Drug Store
TOM BARNETT, PHARMACIST/OWNER
(580) 927-2064
Signed By Date
4/8/2019
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