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WAL-MART PHARMACY 10-0210
CAH371319-02 COAL COUNTY
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Covered Entity Details
Entity Name
COAL COUNTY
Subdivision Name
ABC Medical Clinic of Holdenville - Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH371319-02
Entity Address
1011 N Hinckley St
Holdenville, OK 74848
Medicare Provider Number
371319
Outpatient Facility Provider Number
378513
Participating Start Date
4/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0210
Pharmacy Address
500 E HIGHWAY 270
HOLDENVILLE, OK 74848
Pharmacy Comments
Contract Details
Approval Date
4/6/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Trent Bourland, Chief Executive Officer
(580) 927-2327 Ext: 250
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/6/2020
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