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MERCY PHARMACY SERVICES, LLC
SCH370047-00 MERCY HOSPITAL ARDMORE INC
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Covered Entity Details
Entity Name
MERCY HOSPITAL ARDMORE INC
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370047-00
Entity Address
1011 14TH AVENUE NW
ARDMORE, OK 73401-1889
Medicare Provider Number
370047
Participating Start Date
1/1/2011
Last Recertification Date
8/17/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
MERCY PHARMACY COLETTA
4401 MCAULEY BLVD
STE 1700
OKLAHOMA CITY, OK 73120
Pharmacy Comments
Contract Details
Approval Date
7/16/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JONATHAN R. VITIELLO, SVP Financial Operations & Analytics/Interiim CFO OK Communities
(314) 628-3437
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
7/16/2019
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