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WAL-MART PHARMACY 10-0113
DSH370054 Grady Memorial Hospital
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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
WAL-MART PHARMACY 10-0113
Pharmacy Address
2001 SO 1ST. ST
CHICKASHA, OK 73018
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
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
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/8/2014
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