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DOCTOR'S ORDERS PHARMACY #3
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
DOCTOR'S ORDERS PHARMACY #3
Pharmacy Address
WHITEHALL PHARMACY LLC
500 S LINCOLN AVE
STAR CITY, AR 71667-5208
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/20/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
BRYAN JACKSON, CHIEF ADMINISTRATIVE OFFICER
(870) 541-7141
Contract Pharmacy Representative
Whitehall Pharmacy, LLC.
Lelan Stice, Owner
(870) 850-8010
Signed By Date
10/15/2019
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