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AVITA PHARMACY 1026
DSH370178 ADAIR COUNTY HEALTH CENTER
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Covered Entity Details
Entity Name
ADAIR COUNTY HEALTH CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370178
Entity Address
1401 W. Locust Street
STILWELL, OK 74960
Medicare Provider Number
370178
Participating Start Date
4/1/2015
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1026
Pharmacy Address
PHARMBLUE ARIZONA LLC
1260 S CAMPBELL AVE STE 1152
GREEN VALLEY, AZ 85614-0504
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/25/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alan Adams, Chief Executive Officer
(918) 696-3101
Contract Pharmacy Representative
PharmBlue
Dennis ray Ross, Director of research
(703) 340-9943 Ext: 7033409943
Signed By Date
10/14/2019
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