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CVS 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
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 07780
824 S JACKSON ST
JACKSONVILLE, TX 75766
Pharmacy Comments
Contract Details
Approval Date
10/15/2013
Contract Begin Date
1/1/2014
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
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
10/15/2013
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