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WAL-MART PHARMACY 10-5071
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
WAL-MART PHARMACY 10-5071
Pharmacy Address
6301 NW QUANNAH PARKER TRWAY
LAWTON, OK 73505
Pharmacy Comments
Contract Details
Approval Date
1/21/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID BLACKMON, CHIEF FINANCIAL OFFICER
(580) 355-8620 Ext: 5522
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/21/2014
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