Contract Pharmacy Details

JACKSON APOTHECARY LLC
RRC010024-00 JACKSON HOSPITAL AND CLINIC INC

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

JACKSON APOTHECARY LLC

Pharmacy Address

1842 E MAIN ST
PRATTVILLE, AL 36066-5500

Pharmacy Comments

Contract Details

Approval Date

3/10/2021

Contract Begin Date

4/1/2021

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

Jackson Hospital and Clinics
Thomas Hudson Cobb, Director of Pharmacy
(334) 293-8806

Signed By Date

3/10/2021

340B Drug Pricing Program Database