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TISHOMINGO EXPRESS PHARMACY
CH0614360 FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA
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Covered Entity Details
Entity Name
FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA
Subdivision Name
FAMILY HEALTH CENTER OF SOUTHERN OKLAHOMA
Type
HRSA-Funded Health Center
340B ID
CH0614360
Entity Address
610 E. 24TH STREET
TISHOMINGO, OK 73460
Grant Number
H80CS02454
Participating Start Date
7/1/2004
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
TISHOMINGO EXPRESS PHARMACY
Pharmacy Address
PHARMOLOGY TISHOMINGO ACQUISITION LLC
140 E MAIN ST
TISHOMINGO, OK 73460-2838
Pharmacy Comments
Contract Details
Approval Date
10/8/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TINA JAREE DAVIS, CEO
(580) 371-2343 Ext: 322
Contract Pharmacy Representative
Baker Pharmacy
Ryan Jay Ritter, Owner
(580) 298-6223
Signed By Date
10/8/2020
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