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MERCY PHARMACY SERVICES, LLC
DSH370047 MERCY HOSPITAL ARDMORE
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Covered Entity Details
Entity Name
MERCY HOSPITAL ARDMORE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370047
Entity Address
1011 14TH AVE NW
ARDMORE, OK 73401-1889
Medicare Provider Number
370047
Participating Start Date
1/1/2024
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
MERCY PHARMACY ARDMORE
1011 14TH AVE NW
MERCY PHARMACY SERVICES LLC
ARDMORE, OK 73401
Pharmacy Comments
Contract Details
Approval Date
11/3/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
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
10/12/2023
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