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WALGREEN CO
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
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #10666
640 W GAINES STREET
MONTICELLO, AR 71655-4675
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/18/2022
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