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WALMART PHARMACY 10-3766
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
WALMART PHARMACY 10-3766
Pharmacy Address
2325 SERAN DRIVE
WEWOKA, OK 74884
Pharmacy Comments
Contract Details
Approval Date
10/8/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/20/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Roberta Jeffey, CEO
(405) 379-4287
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/8/2015
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