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WAL-MART PHARMACY 10-0339
RW400106A JEFFERSON COMPREHENSIVE CARE SYSTEM INC
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Covered Entity Details
Entity Name
JEFFERSON COMPREHENSIVE CARE SYSTEM INC
Subdivision Name
COLLEGE STATION CENTER
Type
Ryan White Part D
340B ID
RW400106A
Entity Address
4206 FRAZIER PIKE
COLLEGE STATION, AR 72053
Grant Number
H12HA00106
Participating Start Date
1/1/2007
Last Recertification Date
2/23/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0339
Pharmacy Address
1123 HIGHWAY 79/167 BYPASS
PO BOX 705
FORDYCE, AR 71742
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sandra J. Brown, Chief Executive Officer
(870) 543-2300
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2018
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