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IDABEL EXPRESS PHARMACY
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
IDABEL EXPRESS PHARMACY
Pharmacy Address
IDABEL EXPRESS PHARMACY, LLC
810 SE WASHINGTON ST
IDABEL, OK 74745-3332
Pharmacy Comments
Contract Details
Approval Date
1/2/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amy Gilbreath, CEO
(580) 286-6688
Contract Pharmacy Representative
Baker Pharmacy
Ryan Jay Ritter, Owner
(580) 298-6223
Signed By Date
1/2/2020
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