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WAL-MART PHARMACY 10-1278
SCH370049-00 STILLWATER MEDICAL CENTER AUTHORITY
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Covered Entity Details
Entity Name
STILLWATER MEDICAL CENTER AUTHORITY
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370049-00
Entity Address
1323 W. 6TH Ave
STILLWATER, OK 74074-4306
Medicare Provider Number
370049
Participating Start Date
7/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1278
Pharmacy Address
1506 FIR STREET
PERRY, OK 73077
Pharmacy Comments
Contract Details
Approval Date
4/5/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
ALAN LOVELACE, CHIEF FINANCIAL OFFICER
(405) 742-5729
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/5/2017
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