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WINN DIXIE MONTGOMERY, LLC.
DSH010024 JACKSON HOSPITAL AND CLINIC INC
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Covered Entity Details
Entity Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010024
Entity Address
1725 PINE STREET
MONTGOMERY, AL 36106-1109
Medicare Provider Number
010024
Participating Start Date
9/7/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WINN DIXIE MONTGOMERY, LLC.
Pharmacy Address
WINN DIXIE PHARMACY # 428
5326 HWY 231 SOUTH
WETUMPKA, AL 36092
Pharmacy Comments
Contract Details
Approval Date
9/9/2022
Contract Begin Date
9/12/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/10/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
Southeastern Grociers
David Chism, Seinior Director
(904) 370-6455 Ext: 9043706455
Signed By Date
9/9/2022
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