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RX SHOPPE
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
RX SHOPPE
Pharmacy Address
872 W 13TH ST.
ATOKA, OK 74525
Pharmacy Comments
Contract Details
Approval Date
4/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Billy D Johnson, Chief Executive Officer
(580) 927-2327 Ext: 272
Contract Pharmacy Representative
RX Shoppe
Bob Fredrick, Pharmacist - Owner
(580) 889-3331
Signed By Date
4/8/2019
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