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MERCY PHARMACY SERVICES, LLC
SCH370020-00 MERCY HOSPITAL ADA
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Covered Entity Details
Entity Name
MERCY HOSPITAL ADA
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370020-00
Entity Address
430 NORTH MONTE VISTA
ADA, OK 74820
Medicare Provider Number
370020
Participating Start Date
2/7/2022
Last Recertification Date
Entity Termination Date
3/15/2022
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
MERCY PHARMACY COLETTA
4401 MCAULEY BLVD
STE 1700
OKLAHOMA CITY, OK 73120
Pharmacy Comments
Contract Details
Approval Date
1/31/2022
Contract Begin Date
2/11/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Morris W. Brown, Executive Director - Finance
(580) 421-6128
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
1/14/2022
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