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MERCY PHARMACY SERVICES, LLC
DSH370013 MERCY HOSPITAL OKC
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Covered Entity Details
Entity Name
MERCY HOSPITAL OKC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370013
Entity Address
4300 WEST MEMORIAL ROAD
OKLAHOMA CITY, OK 73120-8304
Medicare Provider Number
370013
Participating Start Date
11/4/2022
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
DBA: MERCY SPECIALTY PHARMACY ST. LOUIS
607 S. NEW BALLAS RD.
STE 1415
SAINT LOUIS, MO 63141
Pharmacy Comments
Contract Details
Approval Date
7/3/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/13/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Christopher F Hahne, Vice President-Finance
(405) 936-5649
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
7/3/2024
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