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MVP WARREN LLC
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
MVP WARREN LLC
Pharmacy Address
101 N MAIN ST
WARREN, AR 71671
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
1/26/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRYAN JACKSON, CHIEF ADMINISTRATIVE OFFICER
(870) 541-7141
Contract Pharmacy Representative
City Drug
Nikki Hood, Pharmacist
(870) 367-5301
Signed By Date
1/18/2022
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