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ALABAMA CVS PHARMACY, L.L.C.
RRC010024-00 JACKSON HOSPITAL AND CLINIC INC
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Covered Entity Details
Entity Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Type
Rural Referral Center
340B ID
RRC010024-00
Entity Address
1725 PINE STREET
MONTGOMERY, AL 36106-1109
Medicare Provider Number
010024
Participating Start Date
4/1/2017
Last Recertification Date
9/6/2022
Entity Termination Date
9/7/2022
Pharmacy Details
Pharmacy Name
ALABAMA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04909
3680 HWY 14
MILLBROOK, AL 36054
Pharmacy Comments
Contract Details
Approval Date
10/7/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/7/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467
Signed By Date
10/7/2017
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