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FRED'S PHARMACY #3966
CH0611930 KIAMICHI FAMILY MEDICAL CENTER
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Covered Entity Details
Entity Name
KIAMICHI FAMILY MEDICAL CENTER
Subdivision Name
Type
HRSA-Funded Health Center
340B ID
CH0611930
Entity Address
6026 BATTIEST PICKENS RD
BROKEN BOW, OK 74728-5037
Grant Number
H80CS00267
Participating Start Date
1/1/2003
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
FRED'S PHARMACY #3966
Pharmacy Address
810 E WASHINGTON ST
IDABEL, OK 74745
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Amy Gilbreath, CEO
(580) 241-5294 Ext: 234
Contract Pharmacy Representative
Fred's Pharmacy
Betty Ngo, Sr. Director 340B Program Operations
(901) 481-0346
Signed By Date
1/17/2017
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