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DSH450194 ETMC JACKSONVILLE (Terminated)
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Main Details
Name
ETMC JACKSONVILLE
Subdivision Name
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450194
Medicare Provider Number
450194
Additional Details
Current Program Status
Terminated
Registration Date
9/15/2010
Participating Start Date
7/1/2017
Participating Approval Date
9/15/2010
Last Recertification Date
11/6/2017
Termination Date
Termination Reason
4/1/2018
For-Profit conversion
Contacts
Authorizing Official
ETMC Jacksonville
Ruth A Cook, Administrator
(903) 541-5100
Primary Contact
ETMC Jacksonville
KENNETH KOO, DIRECTOR OF PHARMACY
(903) 541-5439
Addresses
Street Address
501 S RAGSDALE
JACKSONVILLE, TX 75766
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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6/9/17 Participated as DSH starting 10/1/2010, terminated as DSH effective 4/1/2013 for conversion to SCH entity type, Reinstated as DSH 7/1/2017.
06/09/2017
Convert to SCH 4/1/13.”
04/10/2013
3/29/2013: Converted from DSH to SCH per entity request and OPA concurrence.
04/01/2013
Convert to SCH 4/1/13
03/28/2013
April 2025
April 2025
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