Contract Pharmacy Details

YOUNG'S DRUG STORE
DSH370040 Leflore County Hospital Authority

Covered Entity Details

Entity Name

Leflore County Hospital Authority

Subdivision Name

Eastern Oklahoma Medical Center

Type

Disproportionate Share Hospital

340B ID

DSH370040

Entity Address

105 Wall Street
Poteau, OK 74953-1148

Medicare Provider Number

370040

Participating Start Date

7/1/2013

Last Recertification Date

8/10/2016

Entity Termination Date

4/1/2017

Pharmacy Details

Pharmacy Name

YOUNG'S DRUG STORE

Pharmacy Address

219 DEWEY AVENUE
POTEAU, OK 74953

Pharmacy Comments

Contract Details

Approval Date

7/12/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Melinda Davis, Interim CEO
(918) 635-3319

Contract Pharmacy Representative

Larry Young, RPh
(918) 647-2113

Signed By Date

7/12/2013