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GRANITE DRUG CO.
CAH371330-00 MANGUM REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MANGUM REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371330-00
Entity Address
1 WICKERSHAM DRIVE
MANGUM, OK 73554
Medicare Provider Number
371330
Participating Start Date
4/1/2020
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GRANITE DRUG CO.
Pharmacy Address
MURRAY DRUG CO., LLC
316 NORTH MAIN STREET
PO BOX 158
GRANITE, OK 73547
Pharmacy Comments
Contract Details
Approval Date
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/19/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel J Coffin, Chief Clinical Officer
(580) 782-3353 Ext: 230
Contract Pharmacy Representative
Mangum Drug Co. LLC
Katherine Murrray, CEO, Owner
(580) 782-2195
Signed By Date
4/7/2023
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