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GALLIPOT PHARMACY
CHC06453-00 PUSHMATAHA FAMILY MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
PUSHMATAHA FAMILY MEDICAL CENTER INC.
Subdivision Name
PUSHMATAHA FAMILY MEDICAL CENTER
Type
HRSA-Funded Health Center
340B ID
CHC06453-00
Entity Address
1020 North Lawson Blvd
CLAYTON, OK 74536-0219
Grant Number
H80CS06453
Participating Start Date
1/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
GALLIPOT PHARMACY
Pharmacy Address
AUTARCH MEDICINAL SERVICES, PLLC
213 E MAIN ST STE 100
CALERA, OK 74730
Pharmacy Comments
Contract Details
Approval Date
4/8/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/25/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Angela Batton, CEO
(918) 569-4143
Contract Pharmacy Representative
Gallipot Pharmacy
Josiah Schomer, Pharmacist
(580) 920-5693
Signed By Date
4/8/2020
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