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THE PHARMACY AT BERGHEIM
CAH371319-00 COAL COUNTY
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Covered Entity Details
Entity Name
COAL COUNTY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371319-00
Entity Address
6 NORTH COVINGTON
COALGATE, OK 74538
Medicare Provider Number
371319
Participating Start Date
4/1/2019
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
THE PHARMACY AT BERGHEIM
Pharmacy Address
PREMIUM PHARMA
814 MYER LANE
KERMIT, TX 79745
Pharmacy Comments
Contract Details
Approval Date
7/9/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Trent Bourland, Chief Executive Officer
(580) 927-2327 Ext: 250
Contract Pharmacy Representative
The Pharmacy at Bergheim
Rolando Ramon, Pharmacist
(210) 332-5900
Signed By Date
7/9/2020
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