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SUPER 1 FOODS PHARMACY #622
DSH040071 JEFFERSON REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
JEFFERSON REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040071
Entity Address
1600 WEST 40TH AVENUE
PINE BLUFF, AR 71603
Medicare Provider Number
040071
Participating Start Date
4/1/2000
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
SUPER 1 FOODS PHARMACY #622
Pharmacy Address
2800 S. HAZEL STREET
PINE BLUFF, AR 71603
Pharmacy Comments
Contract Details
Approval Date
1/27/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
BRYAN JACKSON, CHIEF ADMINISTRATIVE OFFICER
(870) 541-7141
Contract Pharmacy Representative
Brookshires
W Mark Sullivan, Pharmacy Operations
(903) 877-6852
Signed By Date
1/27/2019
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