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WINN DIXIE PHARMACY #521
RRC010024-00 JACKSON HOSPITAL AND CLINIC INC
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Covered Entity Details
Entity Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Type
Rural Referral Center
340B ID
RRC010024-00
Entity Address
1725 PINE STREET
MONTGOMERY, AL 36106-1109
Medicare Provider Number
010024
Participating Start Date
4/1/2017
Last Recertification Date
9/6/2022
Entity Termination Date
9/7/2022
Pharmacy Details
Pharmacy Name
WINN DIXIE PHARMACY #521
Pharmacy Address
3881 ATLANTA HWY
MONTGOMERY, AL 36109
Pharmacy Comments
Contract Details
Approval Date
7/13/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
7/13/2018
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