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JAC STORES INC
CAH141301-00 Kirby Medical Center
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Covered Entity Details
Entity Name
Kirby Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141301-00
Entity Address
1000 Medical Center Drive
Monticello, IL 61856
Medicare Provider Number
141301
Participating Start Date
4/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
JAC STORES INC
Pharmacy Address
DBA SAV MOR PHARMACY
407 S. JACKSON ST
CERRO GORDO, IL 61818
Pharmacy Comments
Contract Details
Approval Date
2/1/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Steven D. Tenhouse, Chief Executive Officer
(217) 762-2115 Ext: 1501
Contract Pharmacy Representative
Sav Mor Pharmacies
David Falk, President/owner
(217) 362-6226 Ext: 3
Signed By Date
2/1/2018
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