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BIOPLUS SPECIALTY INFUSION AL 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
BIOPLUS SPECIALTY INFUSION AL LLC
Pharmacy Address
2511 ROSS CLARK CIR
DOTHAN, AL 36301
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
5/10/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
9/9/2022
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