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EASTSIDE PHARMACY
DSH370056 COMANCHE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COMANCHE COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370056
Entity Address
3401 W Gore Blvd
LAWTON, OK 73505
Medicare Provider Number
370056
Participating Start Date
10/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
EASTSIDE PHARMACY
Pharmacy Address
3612 SE LEE BLVD
LAWTON, OK 73501
Pharmacy Comments
Contract Details
Approval Date
10/14/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
George Kruger, CHIEF FINANCIAL OFFICER
(580) 585-5522 Ext: 5522
Contract Pharmacy Representative
Eastside Pharmacy
Brent Brennan, Owner
(580) 355-6400
Signed By Date
10/14/2023
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