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DSH040071C JEFFERSON REGIONAL MEDICAL CENTER (Terminated)
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Main Details
Name
JEFFERSON REGIONAL MEDICAL CENTER
Subdivision Name
Center on Aging
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH040071C
Medicare Provider Number
040071
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
5/31/2012
Participating Start Date
7/1/2012
Participating Approval Date
6/21/2012
Last Recertification Date
8/29/2016
Termination Date
Termination Reason
1/1/2018
Site closure
Contacts
Authorizing Official
Jefferson Regional Medical Center
BRYAN JACKSON, CHIEF ADMINISTRATIVE OFFICER
(870) 541-7141
Primary Contact
Jefferson Regional Medical Center
Lelan Stice, Director of Pharmacy
(870) 541-7908
Addresses
Street Address
4747 Dusty Lake Drive #101
Pine Bluff, AR 71603
Billing Address
JEFFERSON REGIONAL MEDICAL CENTER
1600 W 40th Avenue
Pine Bluff, AR 71603
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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