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RYAN DRUG STORE
CAH371311-00 JEFFERSON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
JEFFERSON COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371311-00
Entity Address
9170 US Hwy 70
INTERSECTION HWY 70 & 81
WAURIKA, OK 73573
Medicare Provider Number
371311
Participating Start Date
1/1/2017
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
RYAN DRUG STORE
Pharmacy Address
520 W WASHINGTON
PO BOX 130
RYAN, OK 73565
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Richard Gillespie, CEO
(580) 228-2344 Ext: 226
Contract Pharmacy Representative
Molly Compton, COO
(580) 757-2230
Signed By Date
4/11/2017
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