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HENRIETTA PHARMACY INC.
CAH451362-02 CLAY COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CLAY COUNTY MEMORIAL HOSPITAL
Subdivision Name
CCMH Clinic
Type
Critical Access Hospital
340B ID
CAH451362-02
Entity Address
102 S. Archer Street
Henrietta, TX 76365
Medicare Provider Number
451362
Outpatient Facility Provider Number
Participating Start Date
10/1/2017
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
HENRIETTA PHARMACY INC.
Pharmacy Address
HENRIETTA PHARMACY
124 N BRIDGE ST
HENRIETTA, TX 76365-2804
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEBRA HAEHN, CFO
(940) 235-1202
Contract Pharmacy Representative
Henrietta Pharmacy
Mark Mathews, Owner
(940) 538-4361
Signed By Date
7/9/2019
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