Contract Pharmacy Details

LIBERTY DRUG
CAH371334-01 CARNEGIE TRI-COUNTY MUNICIPAL HOSPIT

Covered Entity Details

Entity Name

CARNEGIE TRI-COUNTY MUNICIPAL HOSPIT

Subdivision Name

CARNEGIE TRI-COUNTY MUNICIPAL HOSPI - Carnegie Medical Clinic

Type

Critical Access Hospital

340B ID

CAH371334-01

Entity Address

101 W ASH ST
CARNEGIE MEDICAL CLINIC
CARNEGIE, OK 73015-5013

Medicare Provider Number

371334

Outpatient Facility Provider Number

378542

Participating Start Date

4/1/2022

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

LIBERTY DRUG

Pharmacy Address

15 W. MAIN ST
CARNEGIE, OK 73015

Pharmacy Comments

Contract Details

Approval Date

1/6/2022

Contract Begin Date

1/18/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Thomas Henton, CEO
(580) 654-1050

Contract Pharmacy Representative

Liberty Drug
BRIAN HARRISON, OWNER
(580) 654-1111

Signed By Date

1/5/2022

340B Drug Pricing Program Database