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OKLAHOMA CVS PHARMACY, L.L.C.
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
OKLAHOMA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06128
1016 SW LEE BLVD
LAWTON, OK 73501
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
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
1/21/2014
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