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WAL-MART PHARMACY 10-0103
CAH371321-00 Holdenville Hospital Authority
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Covered Entity Details
Entity Name
Holdenville Hospital Authority
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371321-00
Entity Address
100 MCDOUGAL DRIVE
HOLDENVILLE, OK 74848
Medicare Provider Number
371321
Participating Start Date
8/9/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0103
Pharmacy Address
196 SHAWNEE MALL DR
SHAWNEE, OK 74804
Pharmacy Comments
Contract Details
Approval Date
8/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/20/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Roberta Jeffey, CEO
(405) 379-4287
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
8/7/2014
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