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APACHE DRUG
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
APACHE DRUG
Pharmacy Address
118 E EVANS AVE
P.O. BOX 315
APACHE, OK 73006-9190
Pharmacy Comments
Contract Details
Approval Date
1/8/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
George Kruger, CHIEF FINANCIAL OFFICER
(580) 585-5522 Ext: 5522
Contract Pharmacy Representative
Apache Drug
Michael Melton, Owner
(580) 588-3639
Signed By Date
1/8/2020
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