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WALGREEN CO.
CAH451319-00 MOTHER FRANCES HOSPITAL-JACKSONVILLE
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Covered Entity Details
Entity Name
MOTHER FRANCES HOSPITAL-JACKSONVILLE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451319-00
Entity Address
2026 S.JACKSON ST.
JACKSONVILLE, TX 75766
Medicare Provider Number
451319
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS #21249
1329 S JACKSON ST
JACKSONVILLE, TX 75766
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/13/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Barry D. Lofquist, Administrator
(903) 541-4505
Contract Pharmacy Representative
Walgreens
Edwin Raff, DVP Contracting & Pricing
(847) 964-6198
Signed By Date
10/14/2022
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