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WAL-MART PHARMACY 10-0180
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
WAL-MART PHARMACY 10-0180
Pharmacy Address
1311 S. JACKSON
JACKSONVILLE, TX 75766
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS CAMMACK, CEO
(903) 541-4515
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/28/2012
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