Contract Pharmacy Details

GRAND CARE PHARMACY
DSH370054 Grady Memorial Hospital

Covered Entity Details

Entity Name

Grady Memorial Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH370054

Entity Address

2220 W. Iowa
Chickasha, OK 73018-2700

Medicare Provider Number

370054

Participating Start Date

7/1/2012

Last Recertification Date

8/31/2016

Entity Termination Date

1/1/2018

Pharmacy Details

Pharmacy Name

GRAND CARE PHARMACY

Pharmacy Address

2103 WEST IOWA AVENUE
CHICKASHA, OK 73018

Pharmacy Comments

Contract Details

Approval Date

10/11/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

KEAN SPELLMAN, CEO
(405) 779-2150

Contract Pharmacy Representative

Pam Lee, Owner
(405) 222-2273

Signed By Date

10/11/2013