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CYSTIC FIBROSIS SERVICES, LLC
DSH250048 ST. DOMINIC-JACKSON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ST. DOMINIC-JACKSON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250048
Entity Address
969 LAKELAND DRIVE
JACKSON, MS 39216-4606
Medicare Provider Number
250048
Participating Start Date
7/1/2008
Last Recertification Date
8/27/2024
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
7/14/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/20/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sam Scott, Sr Vice President / CFO
(601) 200-6570
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/14/2022
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