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PORTER PHARMACY INC
SCH450194-00 East Texas Medical Center Jacksonville
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Covered Entity Details
Entity Name
East Texas Medical Center Jacksonville
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450194-00
Entity Address
501 South Ragsdale
Jacksonville, TX 75766
Medicare Provider Number
450194
Participating Start Date
4/1/2013
Last Recertification Date
8/18/2016
Entity Termination Date
7/1/2017
Pharmacy Details
Pharmacy Name
PORTER PHARMACY INC
Pharmacy Address
308 WEST LARISSA
JACKSONVILLE, TX 75766
Pharmacy Comments
Contract Details
Approval Date
3/13/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
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
1/14/2013
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