Contract Pharmacy Details

OKLAHOMA CVS PHARMACY, L.L.C.
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

OKLAHOMA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06224
1802 SOUTH 4TH ST.
CHICKASHA, OK 73018

Pharmacy Comments

Contract Details

Approval Date

4/10/2014

Contract Begin Date

7/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/2/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

KEAN SPELLMAN, CEO
(405) 779-2150

Contract Pharmacy Representative

CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298

Signed By Date

4/10/2014

340B Drug Pricing Program Database