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SCH140058-00 Jacksonville Memorial Hospital (Terminated)
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Main Details
Name
Jacksonville Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
Rural
No
340B ID
SCH140058-00
Medicare Provider Number
140058
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2017
Participating Start Date
10/1/2017
Participating Approval Date
7/20/2017
Last Recertification Date
9/15/2021
Termination Date
Termination Reason
7/7/2022
Business decision by the Covered Entity
Contacts
Authorizing Official
Jacksonville Memorial Hospital
William Scott Boston, President & CEO
(217) 479-5523
Primary Contact
Jacksonville Memorial Hospital
Lori L Smith, Director of Pharmacy
(217) 479-5532
Addresses
Street Address
1600 WEST WALNUT
JACKSONVILLE, IL 62650-1185
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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