Contract Pharmacy Details

PORTER PHARMACY INC
DSH450194B ETMC JACKSONVILLE

Covered Entity Details

Entity Name

ETMC JACKSONVILLE

Subdivision Name

ETMC First Physicians Clinic Rusk

Type

Disproportionate Share Hospital

340B ID

DSH450194B

Entity Address

1325 N. Dickinson Drive
Rusk, TX 75785

Medicare Provider Number

450194

Outpatient Facility Provider Number

458891

Participating Start Date

7/1/2017

Last Recertification Date

11/6/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

PORTER PHARMACY INC

Pharmacy Address

308 WEST LARISSA
JACKSONVILLE, TX 75766

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

Eric Evans, President
(903) 586-9804

Signed By Date

7/5/2017