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JAC STORES INC.
CAH141351-00 County of Clay DBA Clay County Hospital
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Covered Entity Details
Entity Name
County of Clay DBA Clay County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141351-00
Entity Address
911 Stacy Burk Dr.
Flora, IL 62839-3241
Medicare Provider Number
141351
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
JAC STORES INC.
Pharmacy Address
SAV-MOR PHARMACY
121 W. NORTH AVENUE
FLORA, IL 62839
Pharmacy Comments
Contract Details
Approval Date
2/19/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/30/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Robert Seller, CFO
(618) 662-1611
Contract Pharmacy Representative
Sav Mor Pharmacies
David Falk, President/owner
(217) 362-6226 Ext: 3
Signed By Date
1/14/2013
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