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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
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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