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MERCY PHARMACY SERVICES, LLC
RRC370013-00 MERCY HOSPITAL OKC
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Covered Entity Details
Entity Name
MERCY HOSPITAL OKC
Subdivision Name
Type
Rural Referral Center
340B ID
RRC370013-00
Entity Address
4300 WEST MEMORIAL ROAD
OKLAHOMA CITY, OK 73120-8304
Medicare Provider Number
370013
Participating Start Date
1/1/2020
Last Recertification Date
8/31/2022
Entity Termination Date
11/4/2022
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
MERCY PHARMACY I-35
2017 W I 35 FRONTAGE RD STE 120
MERCY PHARMACY SERVICES LLC
EDMOND, OK 73013
Pharmacy Comments
Contract Details
Approval Date
11/24/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/4/2022
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
10/9/2019
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