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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 ARDMORE
1011 14TH AVE NW
MERCY PHARMACY SERVICES LLC
ARDMORE, OK 73401
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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