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PUCKETT DISCOUNT PHARMACY
CAH371330-01 MANGUM REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MANGUM REGIONAL MEDICAL CENTER
Subdivision Name
MANGUM CITY HOSPITAL AUTHORITY - Mangum Family Clinic
Type
Critical Access Hospital
340B ID
CAH371330-01
Entity Address
118 S LOUIS TITTLE AVE
MANGUM CLINIC
MANGUM, OK 73554-4441
Medicare Provider Number
371330
Outpatient Facility Provider Number
378541
Participating Start Date
4/1/2022
Last Recertification Date
8/13/2024
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
1/13/2022
Contract Begin Date
2/2/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dale W. Clayton, Administrator
(580) 782-3353
Contract Pharmacy Representative
Puckett Discount Pharmacy
Bradley P Banister, Pharmacist in Charge
(580) 782-2131
Signed By Date
1/10/2022
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