Contract Pharmacy Details

MANGUM DRUG CO
CAH371330-01 MANGUM REGIONAL MEDICAL CENTER

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

MANGUM DRUG CO

Pharmacy Address

MANGUM DRUG CO. LLC
109 S OKLAHOMA AVE
MANGUM, OK 73554-4219

Pharmacy Comments

Contract Details

Approval Date

7/11/2022

Contract Begin Date

7/15/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/18/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Dale W. Clayton, Administrator
(580) 782-3353

Contract Pharmacy Representative

Mangum Drug Co. LLC
Katherine Murrray, CEO, Owner
(580) 782-2195

Signed By Date

7/11/2022

340B Drug Pricing Program Database