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WAL-MART PHARMACY 10-5315
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
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Barry D. Lofquist, Administrator
(903) 541-4505
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2021
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