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CHRISTUS SPECIALTY PHARMACY
DSH450573 CHRISTUS JASPER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CHRISTUS JASPER MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450573
Entity Address
1275 MARVIN HANCOCK DRIVE
JASPER, TX 75951
Medicare Provider Number
450573
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
CHRISTUS SPECIALTY PHARMACY
Pharmacy Address
MOTHER FRANCES REGIONAL HEALTH CARE CTR
800 E DAWSON ST STE 100
TYLER, TX 75701-2036
Pharmacy Comments
Contract Details
Approval Date
6/10/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
10/1/2022
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nikki Martin, Regional Director, Finance
(409) 899-7105
Contract Pharmacy Representative
CHRISTUS Health
Justin Simon, Corporate Director of Pharmacy - Business Services
(214) 704-9531
Signed By Date
6/10/2021
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