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CLINIC PHARMACY
SCH370138-00 MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF TEXAS COUNTY AUTHORITY
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370138-00
Entity Address
520 MEDICAL DRIVE
GUYMON, OK 73942
Medicare Provider Number
370138
Participating Start Date
9/29/2010
Last Recertification Date
12/5/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
CLINIC PHARMACY
Pharmacy Address
1210 N LELIA ST
P O BOX 1590
GUYMON, OK 73942-3647
Pharmacy Comments
Contract Details
Approval Date
10/6/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michele Reust, Controller
(580) 338-6515 Ext: 2244
Contract Pharmacy Representative
Clinic Pharmacy
Chelle Melton, Owner/DPh
(580) 338-3339
Signed By Date
10/6/2015
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