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MERCY PHARMACY SERVICES, LLC
DSH370020 Mercy Hospital ADA Inc.
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Covered Entity Details
Entity Name
Mercy Hospital ADA Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370020
Entity Address
430 N. MONTE VISTA
ADA, OK 74820
Medicare Provider Number
370020
Participating Start Date
3/15/2022
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
D/B/A MERCY COMPOUNDING AND HOME INFUSIO
3183 RIVERPORT TECH CENTER DR
MARYLAND HEIGHTS, MO 63043
Pharmacy Comments
Contract Details
Approval Date
4/12/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marcus Bruner, Executive Director Finance
(580) 220-6239
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
4/12/2024
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