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DSH010024AE JACKSON HOSPITAL AND CLINIC INC (Active)
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Main Details
Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Jackson Clinic - Prim Care - Internal Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH010024AE
Medicare Provider Number
010024
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
7/13/2023
Participating Start Date
10/1/2023
Participating Approval Date
7/14/2023
Last Recertification Date
8/16/2024
Contacts
Authorizing Official
Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806
Primary Contact
Jackson Hospital & Clinic, Inc.
Ashley Cherie Forbus, 340B Program Manager
(334) 293-8788
Addresses
Street Address
1722 Pine Street
ste 1002
Montgomery, AL 36106
Billing Address
Jackson Hospital and Clinic
1725 Pine St
Montgomery, AL 36106
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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