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SCH450194-00 East Texas Medical Center Jacksonville (Terminated)
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Main Details
Name
East Texas Medical Center Jacksonville
Subdivision Name
Type
Sole Community Hospital
Rural
Yes
340B ID
SCH450194-00
Medicare Provider Number
450194
Additional Details
Current Program Status
Terminated
Registration Date
3/27/2013
Participating Start Date
4/1/2013
Participating Approval Date
3/28/2013
Last Recertification Date
8/18/2016
Termination Date
Termination Reason
7/1/2017
Change of covered entity type
Contacts
Authorizing Official
ETMC Athens
Jack R. Endres, Administrator
(903) 541-5100
Primary Contact
ETMC Jacksonville
KENNETH KOO, DIRECTOR OF PHARMACY
(903) 541-5439
Addresses
Street Address
501 South Ragsdale
Jacksonville, TX 75766
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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