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WALGREEN CO.
DSH370078 OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST
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Covered Entity Details
Entity Name
OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST
Subdivision Name
DBA OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH370078
Entity Address
744 WEST 9TH STREET
TULSA, OK 74127
Medicare Provider Number
370078
Participating Start Date
7/1/2009
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #16026
717 S HOUSTON AVE, STE 103
TULSA, OK 74127
Pharmacy Comments
Contract Details
Approval Date
1/7/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Ellis-Muskrat, Chief Operating Officer
(918) 599-5209
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/7/2015
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