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ELGIN DISCOUNT PHARMACY
DSH370056 COMANCHE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COMANCHE COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370056
Entity Address
3401 W Gore Blvd
LAWTON, OK 73505
Medicare Provider Number
370056
Participating Start Date
10/1/2004
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
ELGIN DISCOUNT PHARMACY
Pharmacy Address
7523 US HWY 277
ELGIN, OK 73538
Pharmacy Comments
Contract Details
Approval Date
10/16/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Ownership change
Contacts
Covered Entity Signing Official
DAVID BLACKMON, CHIEF FINANCIAL OFFICER
(580) 355-8620 Ext: 5522
Contract Pharmacy Representative
Mark Deevers, Owner
(580) 492-5007
Signed By Date
10/16/2013
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