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WHITE HALL PHARMACY LLC, DBA DOCTOR'S OR
DSH040071B JEFFERSON REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
JEFFERSON REGIONAL MEDICAL CENTER
Subdivision Name
WHITE HALL HEALTH COMPLEX PHYSICAL THERAPY CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH040071B
Entity Address
1600 WEST HOLLAND AVENUE
WHITE HALL, AR 71602
Medicare Provider Number
040071
Outpatient Facility Provider Number
Participating Start Date
10/1/2009
Last Recertification Date
8/28/2023
Entity Termination Date
8/29/2023
Pharmacy Details
Pharmacy Name
WHITE HALL PHARMACY LLC, DBA DOCTOR'S OR
Pharmacy Address
7240 SHERIDAN RD STE 102
WHITE HALL, AR 71602-3224
Pharmacy Comments
Contract Details
Approval Date
10/2/2009
Contract Begin Date
10/2/2009
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nathan Van Genderen, CFO
(870) 541-7271
Contract Pharmacy Representative
LELAN STICE, VP OPS/OWNER
(870) 850-8010
Signed By Date
9/24/2009
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