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DRUG ROOM
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
DRUG ROOM
Pharmacy Address
1700 W 42ND AVE
PINE BLUFF, AR 71603
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
10/20/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRYAN JACKSON, CHIEF ADMINISTRATIVE OFFICER
(870) 541-7141
Contract Pharmacy Representative
Drug Room
David Stover, Owner/Pharmacist
(870) 536-3980
Signed By Date
10/15/2021
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