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MERCY PHARMACY SERVICES, LLC
SCH370047-00 MERCY HOSPITAL ARDMORE INC
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Covered Entity Details
Entity Name
MERCY HOSPITAL ARDMORE INC
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370047-00
Entity Address
1011 14TH AVENUE NW
ARDMORE, OK 73401-1889
Medicare Provider Number
370047
Participating Start Date
1/1/2011
Last Recertification Date
8/17/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
MERCY PHARMACY SERVICES, LLC
Pharmacy Address
MERCY PHARMACY COLETTA
4401 MCAULEY BLVD
STE 1700
OKLAHOMA CITY, OK 73120
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tracy Enloe, Chief Financial Officer - West Communities
(405) 752-3161
Contract Pharmacy Representative
Mercy
Mark J Jaeger, VP-Ambulatory & Specialty Pharmacy
(314) 628-5607
Signed By Date
1/15/2018
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