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JASPER PHARMACY
DSH040017B NORTH ARKANSAS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH ARKANSAS REGIONAL MEDICAL CENTER
Subdivision Name
MARSHALL FAMILY PRACTICE CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH040017B
Entity Address
211 AIRPORT ROAD
MARSHALL, AR 72650
Medicare Provider Number
040017
Outpatient Facility Provider Number
Participating Start Date
10/1/2010
Last Recertification Date
8/15/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
JASPER PHARMACY
Pharmacy Address
200 WEST CHURCH ST
P.O. BOX 520
JASPER, AR 72641
Pharmacy Comments
Contract Details
Approval Date
10/22/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard McBryde, COO
(870) 414-5156
Contract Pharmacy Representative
Leah Henderson, Owner
(870) 446-5515
Signed By Date
10/22/2014
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