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SSM HEALTH PHARMACY
DSH370037 SSM ST ANTHONY HOSPITAL
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Covered Entity Details
Entity Name
SSM ST ANTHONY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370037
Entity Address
1000 N Lee Ave
OKLAHOMA CITY, OK 73102
Medicare Provider Number
370037
Participating Start Date
10/1/2006
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
SSM HEALTH PHARMACY
Pharmacy Address
1211 FISH HATCHERY RD STE 300
MADISON, WI 53715
Pharmacy Comments
Contract Details
Approval Date
10/7/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shasta Manuel, VP of Finance CFO
(405) 272-7282
Contract Pharmacy Representative
SSM Health
Mo Kharbat, VP Pharmacy Services
(414) 313-5567
Signed By Date
10/7/2019
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