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CITY DRUG STORE OF JACKSBORO
SCH450241-00 FAITH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
FAITH COMMUNITY HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450241-00
Entity Address
215 Chisholm Trail
JACKSBORO, TX 76458
Medicare Provider Number
450241
Participating Start Date
1/1/2017
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
CITY DRUG STORE OF JACKSBORO
Pharmacy Address
CITY DRUG STORE
104 E BELKNAP ST
JACKSBORO, TX 76458
Pharmacy Comments
Contract Details
Approval Date
4/5/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bonnie Blevins, CFO
(940) 550-5704
Contract Pharmacy Representative
Rod Hammond, Owner
(940) 567-5576
Signed By Date
4/5/2017
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