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AMERITA
CAH451319-00 MOTHER FRANCES HOSPITAL-JACKSONVILLE
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Covered Entity Details
Entity Name
MOTHER FRANCES HOSPITAL-JACKSONVILLE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451319-00
Entity Address
2026 S.JACKSON ST.
JACKSONVILLE, TX 75766
Medicare Provider Number
451319
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
AMERITA
Pharmacy Address
CENTRAL LINE INFUSION DALLAS
8080 TRISTAR DR STE 120
IRVING, TX 75063-2823
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Anne Pileggi, Associate Vice President/Administrator
(903) 541-4515
Contract Pharmacy Representative
Amerita, Inc.
Dan Van Valkenburg, Director, 340B Program
(810) 434-2710
Signed By Date
10/10/2019
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