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EAST ALABAMA APOTHECARY STORE 3
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
EAST ALABAMA APOTHECARY STORE 3
Pharmacy Address
1171 GATEWOOD DR STE 1200
AUBURN, AL 36830
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/7/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
EAMC
Trey Bankson, 340B contact
(334) 528-3950
Signed By Date
4/15/2019
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