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DSH040071S JEFFERSON REGIONAL MEDICAL CENTER (Terminated)
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Main Details
Name
JEFFERSON REGIONAL MEDICAL CENTER
Subdivision Name
Pain Specialist of South Arkansas - Pain Clinic
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH040071S
Medicare Provider Number
040071
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/8/2019
Participating Start Date
1/1/2020
Participating Approval Date
11/4/2019
Last Recertification Date
Termination Date
Termination Reason
10/1/2020
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
1609 West 40th Suite 203
Pine Bluff, AR 71603
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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