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WALGREEN CO.
DSH010024 JACKSON HOSPITAL AND CLINIC INC
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Covered Entity Details
Entity Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010024
Entity Address
1725 PINE STREET
MONTGOMERY, AL 36106-1109
Medicare Provider Number
010024
Participating Start Date
9/7/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 06800
703 S MEMORIAL DRIVE
PRATTVILLE, AL 36067
Pharmacy Comments
Contract Details
Approval Date
3/16/2011
Contract Begin Date
5/3/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
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