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DSH450194F ETMC JACKSONVILLE (Terminated)
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Main Details
Name
ETMC JACKSONVILLE
Subdivision Name
ETMC First Physicians Clinic Jacksonville / Ob/Gyn
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450194F
Medicare Provider Number
450194
Outpatient Facility Provider Number
673400
Additional Details
Current Program Status
Terminated
Registration Date
4/12/2017
Participating Start Date
7/1/2017
Participating Approval Date
6/9/2017
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
203 Nacogdoches St
Suite 280
Jacksonville, TX 75766
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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