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PUCKETT DISCOUNT PHARMACY
CAH371330-00 MANGUM REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MANGUM REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371330-00
Entity Address
1 WICKERSHAM DRIVE
MANGUM, OK 73554
Medicare Provider Number
371330
Participating Start Date
4/1/2020
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
PUCKETT DISCOUNT PHARMACY
Pharmacy Address
101 N. LOUIS TITTLE AVE
P O BOX 148
MANGUM, OK 73554-7355
Pharmacy Comments
Contract Details
Approval Date
10/16/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Marie Harrington, CEO
(580) 782-3353 Ext: 249
Contract Pharmacy Representative
Puckett Discount Pharmacy
Bradley P Banister, Pharmacist in Charge
(580) 782-2131
Signed By Date
10/16/2020
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