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VALU-MED PHARMACY
DSH370089 TAHLEQUAH CITY HOSPITAL
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Covered Entity Details
Entity Name
TAHLEQUAH CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370089
Entity Address
1400 E DOWNING
TAHLEQUAH, OK 74464
Medicare Provider Number
370089
Participating Start Date
4/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
VALU-MED PHARMACY
Pharmacy Address
SCOTT'S PHARMACY, LLC
1201 S LEE ST
FORT GIBSON, OK 74434-8757
Pharmacy Comments
Contract Details
Approval Date
3/6/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Scott's Valu-Med
Justin Wilson, Owner
(405) 850-7678
Signed By Date
1/17/2023
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