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REXCO DRUG
SCH370022-01 JACKSON COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JACKSON COUNTY MEMORIAL HOSPITAL
Subdivision Name
HOSPICE / JACKSON COUNTY MEMORIAL HOSPITAL HOSPICE
Type
Sole Community Hospital
340B ID
SCH370022-01
Entity Address
1204 E TAMARACK RD
JACKSON COUNTY MEMORIAL HOSPITAL HOSPICE
ALTUS, OK 73521-1234
Medicare Provider Number
370022
Outpatient Facility Provider Number
371540
Participating Start Date
10/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
REXCO DRUG
Pharmacy Address
REXCO DRUG OF ALTUS, INC
2101 N MAIN ST
ALTUS, OK 73521-1605
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/29/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim King, CHEIF EXECUTIVE OFFICER
(580) 379-5500
Contract Pharmacy Representative
Lonnie Long, Owner
(580) 477-0381
Signed By Date
10/14/2014
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