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ELGIN PHARMACY, LLC
DSH370056 COMANCHE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COMANCHE COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370056
Entity Address
3401 W Gore Blvd
LAWTON, OK 73505
Medicare Provider Number
370056
Participating Start Date
10/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
ELGIN PHARMACY, LLC
Pharmacy Address
12889 COMMERCE ST
ELGIN, OK 73538
Pharmacy Comments
Contract Details
Approval Date
10/1/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
George Kruger, CHIEF FINANCIAL OFFICER
(580) 585-5522 Ext: 5522
Contract Pharmacy Representative
Elgin Pharmacy
Brendan James, Owner/member
(580) 492-5007
Signed By Date
10/1/2020
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