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PORTER PHARMACY INC
DSH450194F ETMC JACKSONVILLE
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Covered Entity Details
Entity Name
ETMC JACKSONVILLE
Subdivision Name
ETMC First Physicians Clinic Jacksonville / Ob/Gyn
Type
Disproportionate Share Hospital
340B ID
DSH450194F
Entity Address
203 Nacogdoches St
Suite 280
Jacksonville, TX 75766
Medicare Provider Number
450194
Outpatient Facility Provider Number
673400
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
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