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CYSTIC FIBROSIS SERVICES, LLC
CAH141352-00 Jacksonville Memorial Hospital
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Covered Entity Details
Entity Name
Jacksonville Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141352-00
Entity Address
1600 WEST WALNUT
JACKSONVILLE, IL 62650
Medicare Provider Number
141352
Participating Start Date
7/7/2022
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
7/7/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William Scott Boston, President & CEO
(217) 479-5523
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/6/2022
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