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HENRY ROBERT'S EXPRESS PHRMCY
SCH370047-00 MERCY HOSPITAL ARDMORE INC
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Covered Entity Details
Entity Name
MERCY HOSPITAL ARDMORE INC
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370047-00
Entity Address
1011 14TH AVENUE NW
ARDMORE, OK 73401-1889
Medicare Provider Number
370047
Participating Start Date
1/1/2011
Last Recertification Date
8/17/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
HENRY ROBERT'S EXPRESS PHRMCY
Pharmacy Address
1316 12TH AVE NW
ARDMORE, OK 73401-1285
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/9/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JONATHAN R. VITIELLO, SVP Financial Operations & Analytics/Interiim CFO OK Communities
(314) 628-3437
Contract Pharmacy Representative
Mercy
Mike Loftus, Director-Pharmacy Services
(417) 820-3487
Signed By Date
4/15/2020
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