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ROGERS PHARMACY # 6 - EDNA
CAH451363-01 JACKSON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
JACKSON COUNTY HOSPITAL
Subdivision Name
Jackson Medical Clinic Edna - Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH451363-01
Entity Address
1013 A S. Wells St.
Edna, TX 77957
Medicare Provider Number
451363
Outpatient Facility Provider Number
Participating Start Date
10/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
ROGERS PHARMACY # 6 - EDNA
Pharmacy Address
1013 S WELLS ST BLDG B
EDNA, TX 77957-4045
Pharmacy Comments
Contract Details
Approval Date
7/10/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lance Smiga, CEO
(361) 782-7800
Contract Pharmacy Representative
Medicine Man Pharmacy
John Rogers, COO
(361) 482-0345
Signed By Date
7/10/2024
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