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PRUETT'S FOOD - PHARMACY #1
CH061193C KIAMICHI FAMILY MEDICAL CENTER
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Covered Entity Details
Entity Name
KIAMICHI FAMILY MEDICAL CENTER
Subdivision Name
Kiamichi Family Medical Center, Inc. - Broken Bow
Type
HRSA-Funded Health Center
340B ID
CH061193C
Entity Address
510 S Park Dr
Broken Bow, OK 74728-5330
Grant Number
H80CS00267
Participating Start Date
10/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
PRUETT'S FOOD - PHARMACY #1
Pharmacy Address
PRUETT'S FOOD, INC.
201 S PARK DR
BROKEN BOW, OK 74728
Pharmacy Comments
Contract Details
Approval Date
10/14/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amy Gilbreath, CEO
(580) 286-6688
Contract Pharmacy Representative
Pruett's Food Pharmacy
Shannon Pruett, Owner
(580) 933-5700
Signed By Date
10/14/2024
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