Contract Pharmacy Details

MAXWELL PHARMACY
DSH450194A ETMC JACKSONVILLE

Covered Entity Details

Entity Name

ETMC JACKSONVILLE

Subdivision Name

ETMC First Physicians Clinic Frankston

Type

Disproportionate Share Hospital

340B ID

DSH450194A

Entity Address

580 N. Frankston Highway
Frankston, TX 75763

Medicare Provider Number

450194

Outpatient Facility Provider Number

458888

Participating Start Date

7/1/2017

Last Recertification Date

11/6/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

MAXWELL PHARMACY

Pharmacy Address

626 NORTH HIGHWAY 155
P O BOX 726
FRANKSTON, TX 75763

Pharmacy Comments

Contract Details

Approval Date

7/5/2017

Contract Begin Date

7/6/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Jack R. Endres, Administrator
(903) 541-5100

Contract Pharmacy Representative

Joseph Maxwell Jr., President
(903) 876-2323

Signed By Date

7/5/2017