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WAL-MART PHARMACY 10-0113
DSH370054A Grady Memorial Hospital
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Covered Entity Details
Entity Name
Grady Memorial Hospital
Subdivision Name
Rush Springs Clinic
Type
Disproportionate Share Hospital
340B ID
DSH370054A
Entity Address
2220 W. Iowa
Chickasha, OK 73018
Medicare Provider Number
370054
Outpatient Facility Provider Number
373449
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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