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WALGREEN CO.
SCH450573-00 JASPER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JASPER MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450573-00
Entity Address
1275 MARVIN HANCOCK DR
JASPER, TX 75951
Medicare Provider Number
450573
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07638
1250 S WHEELER STREET
JASPER, TX 75951
Pharmacy Comments
Contract Details
Approval Date
10/21/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nikki Martin, Regional Director, Finance
(409) 899-7105
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/4/2024
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