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CYSTIC FIBROSIS SERVICES, LLC
DSH040067 MAGNOLIA REGIONAL HEALTH SYSTEM INC D/B/A MAGNOLIA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MAGNOLIA REGIONAL HEALTH SYSTEM INC D/B/A MAGNOLIA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040067
Entity Address
101 HOSPITAL DRIVE
MAGNOLIA, AR 71753
Medicare Provider Number
040067
Participating Start Date
10/1/2016
Last Recertification Date
8/15/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/9/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Rex Jones, CEO
(870) 235-3212
Contract Pharmacy Representative
Magnolia Regional Medical Center
LeeAnn R Scheer, 340B Consultant
(512) 789-8341
Signed By Date
4/10/2018
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