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WALGREEN CO.
SCH370022-00 JACKSON COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JACKSON COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370022-00
Entity Address
1200 EAST PECAN
ALTUS, OK 73521
Medicare Provider Number
370022
Participating Start Date
9/27/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #09670
1132 NORTH MAIN ST.
ALTUS, OK 73521
Pharmacy Comments
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shelley Simmons, VP of Patient Care
(580) 379-5533
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/13/2020
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