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BOISE CITY FAMILY PHARMACY
CAH371307-00 CIMARRON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CIMARRON MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371307-00
Entity Address
100 SOUTH ELLIS
BOISE CITY, OK 73933
Medicare Provider Number
371307
Participating Start Date
10/14/2021
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
BOISE CITY FAMILY PHARMACY
Pharmacy Address
318 W MAIN ST
PO BOX 1208
BOISE CITY, OK 73933-9607
Pharmacy Comments
Contract Details
Approval Date
6/8/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jonathan Gleason, CEO
(580) 544-2501
Contract Pharmacy Representative
Boise City Pharmacy
Kenan Denten, Pharmacist
(580) 302-2875
Signed By Date
6/8/2022
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