Contract Pharmacy Details

KANSAS PHARMACY, LLC
DSH370089 TAHLEQUAH CITY HOSPITAL

Covered Entity Details

Entity Name

TAHLEQUAH CITY HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH370089

Entity Address

1400 E DOWNING
TAHLEQUAH, OK 74464

Medicare Provider Number

370089

Participating Start Date

4/1/2023

Last Recertification Date

8/15/2024

Pharmacy Details

Pharmacy Name

KANSAS PHARMACY, LLC

Pharmacy Address

1119 E TULSA AVE
KANSAS, OK 74347-7055

Pharmacy Comments

Contract Details

Approval Date

7/17/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263

Contract Pharmacy Representative

Kansas Pharmacy
Drew Turner, Owner
(918) 868-6162

Signed By Date

7/17/2017