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WAL-MART PHARMACY 10-5315
DSH370056 COMANCHE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COMANCHE COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370056
Entity Address
3401 W Gore Blvd
LAWTON, OK 73505
Medicare Provider Number
370056
Participating Start Date
10/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
George Kruger, CHIEF FINANCIAL OFFICER
(580) 585-5522 Ext: 5522
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/10/2019
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