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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
DBA: MERCY SPECIALTY PHARMACY ST. LOUIS
607 S. NEW BALLAS RD.
STE 1415
SAINT LOUIS, MO 63141
Pharmacy Comments
Contract Details
Approval Date
7/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Pharmacy closed
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
7/12/2024
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