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WAL-MART PHARMACY 10-0180
DSH450194C ETMC JACKSONVILLE
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Covered Entity Details
Entity Name
ETMC JACKSONVILLE
Subdivision Name
ETMC First Physicians Clinic Jacksonville / Primary Care
Type
Disproportionate Share Hospital
340B ID
DSH450194C
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
WAL-MART PHARMACY 10-0180
Pharmacy Address
1311 S. JACKSON
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
Wal-Mart
Kathi Phelps, Manager 340B Contracts
(479) 277-3719
Signed By Date
7/5/2017
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