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WAL-MART PHARMACY 10-0483
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
WAL-MART PHARMACY 10-0483
Pharmacy Address
1903 COBBS FORD RD
PRATTVILLE, AL 36066
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
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/7/2017
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