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RRC010024-21 JACKSON HOSPITAL AND CLINIC INC (Terminated)
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Main Details
Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
JACKSON CLINIC PRATTVILLE PRIMARY C - Primary Care
Type
Rural Referral Center
Rural
Yes
340B ID
RRC010024-21
Medicare Provider Number
010024
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/6/2022
Participating Start Date
4/1/2022
Participating Approval Date
1/10/2022
Last Recertification Date
9/1/2022
Termination Date
Termination Reason
9/7/2022
Change of hospital entity type
Contacts
Authorizing Official
Jackson Hospital
Joe Riley, CEO
(334) 293-8809
Primary Contact
Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806
Addresses
Street Address
204 MEDICAL CENTER DR
PRATTVILLE, AL 36066-7288
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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