Contract Pharmacy Details

870 SOUTHERN DRUG CORP
DSH370178 ADAIR COUNTY HEALTH CENTER

Covered Entity Details

Entity Name

ADAIR COUNTY HEALTH CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH370178

Entity Address

1401 W. Locust Street
STILWELL, OK 74960

Medicare Provider Number

370178

Participating Start Date

4/1/2015

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

870 SOUTHERN DRUG CORP

Pharmacy Address

D/B/A AVITA PHARMACY 1064
924 MYRTLE AVE
BROOKLYN, NY 11206

Pharmacy Comments

Contract Details

Approval Date

10/15/2021

Contract Begin Date

1/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/25/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Daniel Bradley, Chief Executive Officer
(918) 696-3101

Contract Pharmacy Representative

PharmBlue
Dennis ray Ross, Director of research
(703) 340-9943 Ext: 7033409943

Signed By Date

10/15/2021

340B Drug Pricing Program Database