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PALACE DRUG STORE
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
PALACE DRUG STORE
Pharmacy Address
104 W OHIO AVE
PO BOX 273
COALGATE, OK 74538
Pharmacy Comments
Contract Details
Approval Date
11/10/2010
Contract Begin Date
11/10/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2021
Ownership change
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/3/2010
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