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CHEYENNE PROFESSIONAL DRUG
CAH371303-00 ROGER MILLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ROGER MILLS MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH371303-00
Entity Address
501 SOUTH LL MALES AVENUE
CHEYENNE, OK 73628
Medicare Provider Number
371303
Participating Start Date
7/1/2017
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
CHEYENNE PROFESSIONAL DRUG
Pharmacy Address
413 E BROADWAY AVE
CHEYENNE, OK 73628-5172
Pharmacy Comments
Contract Details
Approval Date
8/2/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cynthia E Duncan, CEO
(580) 497-3336 Ext: 224
Contract Pharmacy Representative
Jaclyn Stephens, Owner
(580) 497-3325
Signed By Date
8/2/2017
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