Contract Pharmacy Details

WALGREEN CO.
CAH371309-00 PAWHUSKA HOSPITAL INC.

Covered Entity Details

Entity Name

PAWHUSKA HOSPITAL INC.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH371309-00

Entity Address

1101 E 15th St
PAWHUSKA, OK 74056

Medicare Provider Number

371309

Participating Start Date

1/1/2020

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #16556
1611 E. 15TH ST.
TULSA, OK 74120

Pharmacy Comments

Contract Details

Approval Date

7/29/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Jason Timothy McBride, Administrator
(918) 287-3232

Contract Pharmacy Representative

Pawhuska Hospital
Alex Stearns, Pharmacist in Charge
(918) 287-3232

Signed By Date

7/29/2020

340B Drug Pricing Program Database