Covered Entity Details

DSH190064 OUR LADY OF THE LAKE (Active) - information as of 5/3/2025 11:30:12 PM

Main Details

Name

OUR LADY OF THE LAKE

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190064

Medicare Provider Number

190064

Additional Details

Current Program Status

Active

Registration Date

3/4/2008

Participating Start Date

4/1/2008

Participating Approval Date

3/12/2008

Last Recertification Date

8/15/2024

Contacts

Authorizing Official

FMOLHS
Jennifer Clowers, Chief Financial Officer
(225) 765-8550

Primary Contact

OUR LADY OF THE LAKE REGIONAL MED CTR
Thomas Greene, Senior Director of Pharmacy, Baton Rouge Market
(225) 765-8786

Addresses

Street Address

REGIONAL MED CTR
5000 HENNESSY BLVD
BATON ROUGE, LA 70808-4375

Billing Address

FMOLHS Accounts Payable
P.O. Box 83880
Baton Rouge, LA 70884

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
LA	2207041,1720160,2202375,2205641	1366436123,1740847771,1831605062,1215365341

Shipping Addresses

Shipping Address 1

LSU Health Baton Rouge North Clinic A Division of Our Lady of Lake
5439 Airline Hwy
Baton Rouge, LA 70805

Shipping Address 2

LSU Health Baton Rouge - Surgical Center
9032 Perkins RD
Baton Rouge, LA 70810

Shipping Address 3

LSU Health Baton Rouge Mid City Clinic
A Division of Our Lady of the Lake
1401 N. Foster Dr.
Baton Rouge, LA 70806

Shipping Address 4

O'Donovan Pharmacy
5131 O'Donovan Drive
Suite 402
Baton Rouge, LA 70808

Shipping Address 5

Our Lady of the Lake St Elizabeth
1125 W Highway 30
Gonzales, LA 70737-5004

Shipping Address 6

Lake Children's Pharmacy
8300 Constantin Blvd
Baton Rouge, LA 70809-3489

Shipping Address 7

Our Lady of the Lake Children's Hospital
8300 Constantin Blvd FL 2
Baton Rouge, LA 70809-3489

Shipping Address 8

Our Lady of the Lake
Regional Med Ctr
5000 Hennessy Blvd
Baton Rouge, LA 70808-4375

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	10/17/2016	01/01/2017		10/17/2016
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	10/17/2016	01/01/2017	09/15/2019	11/11/2020
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	10/17/2016	01/01/2017	09/15/2019	11/11/2020
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/13/2022	10/01/2022		10/01/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/14/2022	10/01/2022		10/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	10/17/2016	01/01/2017	09/15/2019	11/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	10/17/2016	01/01/2017	09/15/2019	11/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	10/17/2016	01/01/2017	09/15/2019	11/11/2020
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/14/2022	10/01/2022		10/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/14/2022	10/01/2022		10/01/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/14/2022	10/01/2022	01/31/2024	02/09/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/14/2022	10/01/2022		10/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/14/2022	10/01/2022	01/19/2025	01/23/2025
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	10/15/2018	01/01/2019	06/16/2020	06/22/2020
Contract Detail	FRANCISCAN MISSIONARIES OF OUR LADY HEAL	DBA RXONE MED PLAZA	7777 HENNESSY BLVD. STE. 114	BATON ROUGE	LA	70808	01/12/2018	04/01/2018		01/12/2018
Contract Detail	FRANCISCAN MISSIONARIES OF OUR LADY HEAL	DBA RXONE ASCENSION	1014 WEST ST. CLAIRE BLVD STE 1010	GONZALES	LA	70737	01/12/2018	04/01/2018		01/12/2018
Contract Detail	FRANCISCAN MISSIONARIES OF OUR LADY HEAL	RXONE ST FRANCIS	309 JACKSON ST FLOOR 1	MONROE	LA	71201-7407	07/22/2020	10/01/2020		10/01/2020
Contract Detail	FRANCISCAN MISSIONARIES OF OUR LADY HEAL	DBA RXONE TOWER DRIVE	2600 TOWER DR STE 102	MONROE	LA	71201	07/22/2020	10/01/2020		10/01/2020
Contract Detail	FRANCISCAN MISSIONARIES OF OUR LADY HEAL	DBA RXONE LOURDES	4809 AMBASSADOR CAFFERY PKWY STE 120A	LAFAYETTE	LA	70508	10/23/2020	01/01/2021		01/01/2021
Contract Detail	INFUSION PARTNERS, LLC	DBA BIOSCRIP INFUSION SERVICES	5225 O'DONOVAN DRIVE SUITE 101	BATON ROUGE	LA	70808-7203	10/17/2016	01/01/2017	06/16/2020	06/22/2020
Contract Detail	INFUSION PARTNERS, LLC	DBA BIOSCRIP INFUSION SERVICES	5401 JEFFERSON HWY STE B	NEW ORLEANS	LA	70123-4228	10/17/2016	01/01/2017	06/16/2020	06/22/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01116	7777 BLUEBONNET BLVD,, SUITE 100	BATON ROUGE	LA	70810	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01661	17122 AIRLINE HWY.	PRAIRIEVILLE	LA	70769	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05319	5889 AIRLINE HWY	BATON ROUGE	LA	70805	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05322	9608 JEFFERSON HWY	BATON ROUGE	LA	70809	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05324	3384 GOVERNMENT ST	BATON ROUGE	LA	70806	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05510	11705 COURSEY BLVD.	BATON ROUGE	LA	70816	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05615	2520 PLANK RD	BATON ROUGE	LA	70805	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05617	29881 WALKER RD. SOUTH/ PO BOX 1448	WALKER	LA	70785	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY #06124	7411 FLORIDA BLVD.	BATON ROUGE	LA	70806	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	LOUISIANA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08309	5360 HIGHLAND RD.,	BATON ROUGE	LA	70808	01/14/2015	04/01/2015	06/29/2019	11/11/2020
Contract Detail	MAXOR SPECIALTY PHARMACY	216 S POLK ST		AMARILLO	TX	79101-1407	10/16/2017	01/01/2018	06/16/2020	06/22/2020
Contract Detail	MEDICAL PLAZA PHARMACY	7777 HENNESSY BLVD	SUITE 114	BATON ROUGE	LA	70808	04/12/2013	07/01/2013	10/16/2017	10/16/2017
Contract Detail	OUR LADY OF THE LAKE HOSPITAL INC.	DBA - OUR LADY OF THE LAKE LIVINGSTON PH	5000 O'DONOVAN BLVD. STE. 104	WALKER	LA	70785	04/12/2013	07/01/2013	10/16/2017	10/16/2017
Contract Detail	RXONE LAKE	5000 HENNESSY BLVD	CHAPEL HALLWAY RM 101	BATON ROUGE	LA	70808	01/12/2018	04/01/2018		01/12/2018
Contract Detail	WALGREEN CO		710 OVILLA ROAD	WAXAHACHIE	TX	75167	02/28/2013	04/01/2013	08/31/2015	09/03/2015
Contract Detail	WALGREEN CO		15998 WALGREENS DRIVE	JUPITER	FL	33478	02/28/2013	04/01/2013	08/31/2015	09/03/2015
Contract Detail	WALGREEN CO	DBA: WALGREENS	28727 OREGON ROAD	PERRYSBURG	OH	43551	02/28/2013	04/01/2013	08/31/2015	09/03/2015
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03047	5112 ESSEN LANE	BATON ROUGE	LA	70809	11/26/2012	01/01/2013	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02980	4747 S SHERWOOD FOREST	BATON ROUGE	LA	70816	11/26/2012	01/01/2013	10/01/2022	10/04/2022
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03610	12881 PERKINS RD.	BATON ROUGE	LA	70810	11/26/2012	01/01/2013	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02995	3550 GOVERNMENT ST	BATON ROUGE	LA	70806	11/26/2012	01/01/2013	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03399	7620 JEFFERSON HIGHWAY	BATON ROUGE	LA	70809	11/26/2012	01/01/2013	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 07083	9983 BLUEBONNET BLVD	BATON ROUGE	LA	70810	11/26/2012	01/01/2013	10/01/2022	10/04/2022
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 03085	14444 COURSEY BLVD.	BATON ROUGE	LA	70817	11/26/2012	01/01/2013	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 06028	9820 OLD HAMMOND HWY	BATON ROUGE	LA	70816	11/26/2012	01/01/2013	10/01/2022	10/04/2022
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 06448	4485 PERKINS ROAD	BATON ROUGE	LA	70808-3034	11/26/2012	01/01/2013	10/01/2022	10/04/2022
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA WALGREENS SPECIALTY PHARMACY #16478	5555 ESSEN LN STE C	BATON ROUGE	LA	70809	07/14/2022	10/01/2022	01/19/2025	01/23/2025
Contract Detail	WALGREEN LOUISIANA CO., INC.	DBA: WALGREENS # 02982	5450 PLANK ROAD	BATON ROUGE	LA	70805	07/14/2022	10/01/2022	01/19/2025	01/23/2025
Contract Detail	Walgreens #21373	Walgreens Central Fill #21373	4100 Dale Earnhardt Way STE 200	Northlake	TX	76262	04/14/2023	07/01/2023	01/19/2025	01/23/2025
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/12/2013	07/01/2013	08/31/2015	09/03/2015
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/12/2013	07/01/2013	08/31/2015	09/03/2015
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/14/2022	10/01/2022	01/19/2025	01/23/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/14/2022	10/01/2022	01/19/2025	01/23/2025
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/14/2022	10/01/2022	01/19/2025	01/23/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH190064AA	Child	DSH	OUR LADY OF THE LAKE	OLOL Voice Center	4950 Essen Lane	Baton Rouge	LA	Active
DSH190064AB	Child	DSH	OUR LADY OF THE LAKE	OLOL Head and Neck Center	4950 Essen Lane	Baton Rouge	LA	Active
DSH190064AC	Child	DSH	OUR LADY OF THE LAKE	OLOL Hearing and Balance Center	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064AD	Child	DSH	OUR LADY OF THE LAKE	Lake Imaging Center	7135 Perkins Rd	Baton Rouge	LA	Active
DSH190064AE	Child	DSH	OUR LADY OF THE LAKE	Pediatric Physical Medicine Clinic	8415 Goodwood Blvd	Baton Rouge	LA	Active
DSH190064AF	Child	DSH	OUR LADY OF THE LAKE	OLOL Sleep Center	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064AG	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Livingston	5000 O'Donavan Blvd	Walker	LA	Active
DSH190064AH	Child	DSH	OUR LADY OF THE LAKE	LSU Health Imaging PSC / Imaging	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064AJ	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	Lake Main Campus-Advanced Imaging	4950 ESSEN LANE	BATON ROUGE	LA	Terminated
DSH190064AK	Child	DSH	OUR LADY OF THE LAKE	OUR LADY OF THE LAKE RHEUM SERVICES - Rheumatology	7777 HENNESSEY BLVD	BATON ROUGE	LA	Active
DSH190064AL	Child	DSH	OUR LADY OF THE LAKE	OUR LADY OF THE LAKE WOUND AND HYPE - Wound Care	7301 HENNESSY BLVD	BATON ROUGE	LA	Active
DSH190064AM	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Urology Surgery	7777 Hennessy	Baton Rouge	LA	Active
DSH190064AN	Child	DSH	OUR LADY OF THE LAKE	North ER - Emergency - Emergency Services	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064AP	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	OUR LADY OF THE LAKE INFUSION CENTE - Oncology	500 RUE DE LA VIE	BATON ROUGE	LA	Terminated
DSH190064AQ	Child	DSH	OUR LADY OF THE LAKE	LSU - Midcity Urgent Care - Urgent Care	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064AR	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - NEUROLOGY - NEUROLOGY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AS	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SURGERY - ASC - SURGERY	1014 Saint Clair Blvd	Gonzales	LA	Active
DSH190064AT	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - EMERGENCY ROOM - EMERGENCY SERVICES	1125 W Highway 30	Gonzales	LA	Active
DSH190064AU	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SURGERY - MAIN - SURGERY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AV	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - PHYSICAL MEDICINE - PHYSICAL MEDICINE	1125 W Highway 30	Gonzales	LA	Active
DSH190064AW	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - SLEEP LAB - SLEEP LAB	1125 W Highway 30	Gonzales	LA	Active
DSH190064AX	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - RADIOLOGY - IMAGING	1125 W Highway 30	Gonzales	LA	Active
DSH190064AY	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - RESPIRATORY CARE - RESPIRATORY	1125 W Highway 30	Gonzales	LA	Active
DSH190064AZ	Child	DSH	OUR LADY OF THE LAKE	Observation -OLOL STE - ICU - INTENSIVE CARE	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064B	Child	DSH	OUR LADY OF THE LAKE	Family Practice Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064BA	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - WOUND CARE - WOUND CARE	1125 W Highway 30	Gonzales	LA	Active
DSH190064BB	Child	DSH	OUR LADY OF THE LAKE	Observation - OLOL STE - MEDICINE - MEDICINE	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BC	Child	DSH	OUR LADY OF THE LAKE	Observation - OLOL STE - TELEMETRY - TELEMETRY	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BD	Child	DSH	OUR LADY OF THE LAKE	Observation-OLOL STE - SURGERY UNIT - SURGERY	1125 W Highway 30	Gonzales	LA	Terminated
DSH190064BE	Child	DSH	OUR LADY OF THE LAKE	OLOL STE - ENDOSCOPY - ENDOSCOPY	1125 W Highway 30	Gonzales	LA	Active
DSH190064BF	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Emergency Department - Emergency Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BG	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Hematology/Oncology - Hematology & Oncology	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BH	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Physical Therapy - Physical Medicine	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BJ	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - OR MAIN - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BK	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Surgical - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BL	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	Lake Children's Hospital - Dialysis - Dialysis	8300 Constantin Blvd	Baton Rouge	LA	Terminated
DSH190064BM	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Wound Care - Wound Care	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BN	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Radiology - Imaging Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BP	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - PACU - Recovery Room	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BQ	Child	DSH	OUR LADY OF THE LAKE	Lake Children's Hospital - Preop - Surgical Services	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064BR	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEPHROLOGY - Pediatric Nephrology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BS	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S PULMONARY - Pediatric Pulmonary	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BT	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ORTHOPEDIC - Pediatric Orthopedic	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BU	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ADOLESCENT MEDICINE - Pediatric Adolescent Medicine	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BV	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ALLERGY&IMMUNOLOGY - Pediatric Allergy & Immunology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BW	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEUROSURGERY - Pediatric Neurosurgery	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BX	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S INFECTIOUS DISEASE - Pediatric Infectious Disease	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BY	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ENDOCRINOLOGY - Pediatric Endocrinology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064BZ	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S GASTROENTEROLOGY - Pediatric Gastroenterology	8200 Constantin Blvd	Baton Rouge	LA	Active
DSH190064C	Child	DSH	OUR LADY OF THE LAKE	Early Interven HIV Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064CA	Child	DSH	OUR LADY OF THE LAKE	LSU North Baton Rouge Imaging - Imaging Services	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064CB	Child	DSH	OUR LADY OF THE LAKE	OLOL Livingston Imaging - Imaging Services	5000 O'Donovan Blvd	Walker	LA	Active
DSH190064CC	Child	DSH	OUR LADY OF THE LAKE	OLOL Livingston Cardiac Imaging - Imaging Services	5000 O'Donovan Blvd	Walker	LA	Active
DSH190064CD	Child	DSH	OUR LADY OF THE LAKE	LSU Health Baton Rouge MidCity Clinic Imaging Services	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064CE	Child	DSH	OUR LADY OF THE LAKE	OLOL Ascension Heart Vascular Ctr - Cath Lab	1125 W Highway 30	Gonzales	LA	Active
DSH190064CF	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S ENT - Ear, Nose, and Throat	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064CG	Child	DSH	OUR LADY OF THE LAKE	Our Lady of the Lake Advanced Diagnostics - Imaging	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064CH	Child	DSH	OUR LADY OF THE LAKE	OLOL CHILDREN'S NEUROLOGY - Pediatric Neurology	8200 CONSTANTIN BLVD	BATON ROUGE	LA	Active
DSH190064CJ	Child	DSH	OUR LADY OF THE LAKE	St Elizabeth Infusion	2647 St Elizabeth Blvd	Gonzales	LA	Active
DSH190064CK	Child	DSH	OUR LADY OF THE LAKE	Lake Main Campus-OP Diabetes Management - Diabetes	2041 Silverside Dr	Baton Rouge	LA	Approved
DSH190064CL	Child	DSH	OUR LADY OF THE LAKE	Lake Childrens Hospital-Respiratory - Respiratory	8300 Constantin Blvd	Baton Rouge	LA	Approved
DSH190064CM	Child	DSH	OUR LADY OF THE LAKE	LSU Mid City Location-Diabetes and Nutrition - Nutrition	1401 N Foster Dr	Baton Rouge	LA	Approved
DSH190064D	Child	DSH	OUR LADY OF THE LAKE	Diab Ft & Wound Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064E	Child	DSH	OUR LADY OF THE LAKE	Dermatology Mid City Clinic	1401 N Foster Drive	Baton Rouge	LA	Active
DSH190064F	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Adult Ophthalmology	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064G	Child	DSH	OUR LADY OF THE LAKE	LSU North-Oral Surgery Clinic	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064H	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Adult Orthopedic Surgery	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064J	Child	DSH	OUR LADY OF THE LAKE	Infusion North BR Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064K	Child	DSH	OUR LADY OF THE LAKE	Oncology North BR Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064L	Child	DSH	OUR LADY OF THE LAKE	North BR Clinic Primary Care	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064M	Child	DSH	OUR LADY OF THE LAKE	LSU North-Urgent Care Clinic	5439 Airline Hwy	Baton Rouge	LA	Active
DSH190064N	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Endoscopy	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064P	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-Operating Room	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064Q	Child	DSH	OUR LADY OF THE LAKE	LSU Perkins-PACU	9032 Perkins Road	Baton Rouge	LA	Active
DSH190064R	Child	DSH	OUR LADY OF THE LAKE	Medicine OLOL MOB IV Clinic	5131 O'Donovan Drive	Baton Rouge	LA	Active
DSH190064S	Child	DSH	OUR LADY OF THE LAKE	Medicine Subspecialty OLOL MOB IV Clinic	5131 O'Donovan Drive	Baton Rouge	LA	Active
DSH190064T	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	South BR Clinic	950 E Washington	Baton Rouge	LA	Terminated
DSH190064U	Child	DSH	OUR LADY OF THE LAKE REGIONAL MED CTR	LSU Perkins-Pre Admit	9032 Perkins Road	Baton Rouge	LA	Terminated
DSH190064V	Child	DSH	OUR LADY OF THE LAKE	Louisiana Cardiology Associates Imaging	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064W	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	Our Lady of the Lake Outpatient Infusion at Picardy	8119 Picardy Avenue	Baton Rouge	LA	Terminated
DSH190064X	Child	DSH	OUR LADY OF THE LAKE	St. Jude Baton Rouge Affiliate Clinic	8300 Constantin Blvd	Baton Rouge	LA	Active
DSH190064Y	Child	DSH	OUR LADY OF THE LAKE	Lake Main Campus-Infusion	7777 Hennessy Blvd	Baton Rouge	LA	Active
DSH190064Z	Child	DSH	OUR LADY OF THE LAKE HOSPITAL, INC.	Franciscan Clinic	7777 Hennessy Blvd	Baton Rouge	LA	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Ascension 1125 W Highway 30 Gonzales, LA 70737-5004	Our Lady of the Lake St Elizabeth 1125 W Highway 30 Gonzales, LA 70737-5004	4/4/2025 9:15 AM
Addresses	Billing Address	Update	Change Request	FMOLHS Accounts Payable 5000 Hennessy Boulevard Baton Rouge, LA 70808	FMOLHS Accounts Payable P.O. Box 83880 Baton Rouge, LA 70884	1/8/2025 5:40 PM
Details	Last Recertification Date	Update	Recertification	9/2/2023 12:16:34 PM	8/15/2024 2:33:21 PM	8/15/2024 2:33 PM
Addresses	Main Address	Update	Change Request	5000 HENNESSY BLVD. ATTN: Pharmacy BATON ROUGE, LA 70808-4375	REGIONAL MED CTR 5000 HENNESSY BLVD BATON ROUGE, LA 70808-4375	2/5/2024 7:57 AM
Addresses	Shipping Address	Update	Change Request	LSU Health Baton Rouge - Surgical Center Pharmacy 9032 Perkins Road Baton Rouge, LA 70810	LSU Health Baton Rouge - Surgical Center 9032 Perkins RD Baton Rouge, LA 70810	2/5/2024 7:57 AM
Addresses	Shipping Address	Update	Change Request	Mid City Pharmacy 1401 N Foster Drive Baton Rouge, LA 70806	LSU Health Baton Rouge Mid City Clinic A Division of Our Lady of the Lake 1401 N. Foster Dr. Baton Rouge, LA 70806	2/5/2024 7:57 AM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Regional Med Ctr 5000 Hennessy Boulevard ATTN: Pharmacy Baton Rouge, LA 70808-4375	Our Lady of the Lake Regional Med Ctr 5000 Hennessy Blvd Baton Rouge, LA 70808-4375	2/5/2024 7:57 AM
Details	Entity Name	Update	Change Request	OUR LADY OF THE LAKE REGIONAL MED CTR	OUR LADY OF THE LAKE	2/5/2024 7:57 AM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Children's Hospital 8300 Constantin Blvd Baton Rouge, LA 70809	Our Lady of the Lake Children's Hospital 8300 Constantin Blvd FL 2 Baton Rouge, LA 70809-3489	1/5/2024 9:15 AM
Addresses	Main Address	Update	Change Request	5000 HENNESSY BLVD. BATON ROUGE, LA 70808	5000 HENNESSY BLVD. ATTN: Pharmacy BATON ROUGE, LA 70808-4375	12/22/2023 7:28 AM
Addresses	Billing Address	Update	Change Request	FMOLHS Accounts Payable P.O. Box 83880 Baton Rouge, LA 70884	FMOLHS Accounts Payable 5000 Hennessy Boulevard Baton Rouge, LA 70808	12/22/2023 7:28 AM
Addresses	Shipping Address	Insert	Change Request		Our Lady of the Lake Regional Med Ctr 5000 Hennessy Boulevard ATTN: Pharmacy Baton Rouge, LA 70808-4375	12/22/2023 7:28 AM
Contacts	Primary Contact	Update	Profile Change Request	Greene, Thomas Director of Integrated Pharmacy Operations OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	Greene, Thomas Senior Director of Pharmacy, Baton Rouge Market OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	10/12/2023 3:42 PM
Addresses	Shipping Address	Update	Change Request	LSU Health Baton Rouge - North Clinic Pharmacy A Division of Our Lady of the Lake 5439 Airline Hwy Baton Rouge, LA 70805	LSU Health Baton Rouge North Clinic A Division of Our Lady of Lake 5439 Airline Hwy Baton Rouge, LA 70805	9/11/2023 1:37 PM
Addresses	Shipping Address	Delete	Change Request	Our Lady of the Lake Outpatient Oncology 4950 Essen Ln Baton Rouge, LA 70809-3738		9/11/2023 1:37 PM
Addresses	Shipping Address	Delete	Change Request	Our Lady of the Lake Infusion Center 500 Rue De La Vie St 425 Baton Rouge, LA 70817-5127		9/11/2023 1:37 PM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Ascension Pharmacy 1125 W Highway 30 Gonzales, LA 70737-5004	Our Lady of the Lake Ascension 1125 W Highway 30 Gonzales, LA 70737-5004	9/11/2023 1:37 PM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Children's Hosptial 8300 Constantin Blvd Baton Rouge, LA 70809	Our Lady of the Lake Children's Hospital 8300 Constantin Blvd Baton Rouge, LA 70809	9/11/2023 1:37 PM
Details	Entity Name	Update	Change Request	OUR LADY OF THE LAKE HOSPITAL, INC.	OUR LADY OF THE LAKE REGIONAL MED CTR	9/11/2023 1:37 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 6:59:42 AM	9/2/2023 12:16:34 PM	9/2/2023 12:16 PM
Contacts	Primary Contact	Update	Change Request	Mellor, Britney Ross Senior Director of Pharmacy Our Lady of the Lake Regional Medical Center 2257653067	Greene, Thomas Director of Integrated Pharmacy Operations OUR LADY OF THE LAKE REGIONAL MED CTR 2257658786	4/17/2023 7:51 AM
Details	Last Recertification Date	Update	Recertification	8/31/2021 8:40:09 AM	8/26/2022 6:59:42 AM	8/26/2022 6:59 AM
Addresses	Shipping Address	Delete	Change Request	Our Lady of the Lake Livingston 5000 O'Donavan Blvd 2nd Floor Pharmacy Walker, LA 70785		8/11/2022 3:55 PM
Contacts	Authorizing Official	Update	Change Request	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	Clowers, Jennifer Chief Financial Officer FMOLHS 2257658550	8/11/2022 3:55 PM
Medicaid Billing	Medicaid: Number	Delete	Group Change Request	1938589 (LA)		12/15/2021 4:10 PM
Addresses	Billing Address	Update	Group Change Request	Our Lady of the Lake REG MED CTR ATTN PHARMACY PO Box 83880 Baton Rouge, LA 70884-3880	FMOLHS Accounts Payable P.O. Box 83880 Baton Rouge, LA 70884	12/8/2021 9:36 AM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Livingston 5000 O'Donavan Blvd Walker, LA 70785	Our Lady of the Lake Livingston 5000 O'Donavan Blvd 2nd Floor Pharmacy Walker, LA 70785	10/15/2021 9:56 AM
Details	Last Recertification Date	Update	Recertification	9/14/2020 11:08:46 AM	8/31/2021 8:40:09 AM	8/31/2021 8:40 AM
Addresses	Shipping Address	Update	Change Request	LSU Health Baton Rouge - North Clinic Pharmacy 5439 Airline Hwy Baton Rouge, LA 70805	LSU Health Baton Rouge - North Clinic Pharmacy A Division of Our Lady of the Lake 5439 Airline Hwy Baton Rouge, LA 70805	7/23/2021 12:56 PM
Addresses	Shipping Address	Update	Change Request	Our Lady of the Lake Livingston 5000 O'Donovan Blvd Walker, LA 70785	Our Lady of the Lake Livingston 5000 O'Donavan Blvd Walker, LA 70785	7/23/2021 12:56 PM
Addresses	Shipping Address	Update	Change Request	OLOL Children's Hospital Pharmacy 8300 Constantin Blvd 2nd Floor Baton Rouge, LA 70809	Our Lady of the Lake Children's Hosptial 8300 Constantin Blvd Baton Rouge, LA 70809	7/23/2021 12:56 PM
Addresses	Billing Address	Insert	Change Request		Our Lady of the Lake REG MED CTR ATTN PHARMACY PO Box 83880 Baton Rouge, LA 70884-3880	6/14/2021 8:02 AM
Contacts	Primary Contact	Update	Change Request	Mohundro, Michael Marlan Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	Mellor, Britney Ross Senior Director of Pharmacy Our Lady of the Lake Regional Medical Center 2257653067	5/12/2021 10:02 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	127947105 (AR)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	68957 (AZ)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	8087863 (CT)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	96632100 (FL)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	720423651001 (IL)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1370287 (KY)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	20433 (MS)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	666823 (NJ)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1461150 (NY)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200036510A (OK)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	500613214 (OR)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1019706740001 (PA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10738B (SC)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1005587 (AK)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (AL)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (CA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	95015574 (CO)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	8050061 (CT)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	46047631 (DC)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (DE)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	000393181X (GA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	579664 (IA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	300018975 (IN)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (ID)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	200270200A (KS)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	616017400 (MD)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (ME)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MI)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MN)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (MO)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	427737 (MT)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1900064 (NC)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	51051737 (NM)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (NV)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	440437 (OH)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	190064 (TN)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	107816401 (TX)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1010764 (UT)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (VA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	6703509 (VT)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	2037942 (WA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1366436123 (WI)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	3810009186 (WV)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	10026685900 (NE)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110128871A (MA)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	110128871B (MA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (PA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (SC)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (KY)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AR)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NY)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OK)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MS)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OR)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NJ)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AZ)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IL)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CT)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CO)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (FL)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AK)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (AL)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (CA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (DC)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (DE)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (GA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (IN)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (ID)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (KS)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MD)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (ME)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MI)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MN)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MO)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (MT)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NC)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NM)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NV)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (OH)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (TN)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (TX)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (UT)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (VA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (VT)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WA)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WI)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (WV)		3/21/2021 3:17 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1366436123 (NE)		3/21/2021 3:17 PM
Medicaid Billing	Medicaid: Number	Delete	Recertification	2207041 (LA)		9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	9000175251 (CO)		9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1938589	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1005587	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AK	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		AL	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		95015574	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		8050061	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		46047631	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DC	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		DE	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		000393181X	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		579664	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		300018975	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		IN	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ID	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200270200A	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		KS	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		616017400	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MD	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		ME	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MI	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MN	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MO	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		427737	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MT	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1900064	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		51051737	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NM	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NV	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		440437	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		OH	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		190064	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		107816401	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TX	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1010764	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		UT	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		6703509	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		VT	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2037942	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		3810009186	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WV	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10026685900	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NE	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110128871A	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		110128871B	9/14/2020 11:08 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		MA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1740847771 ( )		9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1366436123 ( )		9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1215365341 ( )		9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1740847771	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1831605062	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1215365341	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		KY	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		AR	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		OK	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MS	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		OR	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		AZ	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CT	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CO	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		AK	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		AL	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		CA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		DC	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		DE	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		IA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		IN	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		ID	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		KS	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MD	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		ME	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MN	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MO	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MT	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NM	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NV	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		OH	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		UT	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		VA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		VT	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		WA	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		WV	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/14/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		NE	9/14/2020 11:08 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1831605062 ( )		9/14/2020 11:08 AM
Details	Last Recertification Date	Update	Recertification	9/16/2019 4:51:42 PM	9/14/2020 11:08:46 AM	9/14/2020 11:08 AM
Contacts	Authorizing Official	Update	AO Change Request	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550-2259077045	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	4/22/2020 1:40 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/8/2019 1:33 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2207041	10/8/2019 1:33 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	10/8/2019 1:33 PM
Addresses	Shipping Address	Insert	Recertification		OLOL Children's Hospital Pharmacy 8300 Constantin Blvd 2nd Floor Baton Rouge, LA 70809	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2207041	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		127947105	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AR	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		68957	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		AZ	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		9000175251	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CO	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		8087863	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		CT	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		96632100	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		720423651001	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		IL	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1370287	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		KY	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		20433	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		MS	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		666823	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1461150	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		200036510A	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OK	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		500613214	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		OR	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1019706740001	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		10738B	9/16/2019 4:51 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/16/2019 4:51 PM
Details	Last Recertification Date	Update	Recertification	9/11/2018 7:30:10 AM	9/16/2019 4:51:42 PM	9/16/2019 4:51 PM
Contacts	Authorizing Official	Update	New Registration	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550-2259077045	7/15/2019 5:01 PM
Addresses	Shipping Address	Insert	Change Request		Lake Children's Pharmacy 8300 Constantin Blvd Baton Rouge, LA 70809-3489	6/25/2019 12:31 PM
Addresses	Shipping Address	Insert	Change Request		Our Lady of the Lake Ascension Pharmacy 1125 W Highway 30 Gonzales, LA 70737-5004	6/25/2019 7:10 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1740847771	6/25/2019 7:10 AM
Addresses	Shipping Address	Insert	Change Request		Our Lady of the Lake Infusion Center 500 Rue De La Vie St 425 Baton Rouge, LA 70817-5127	4/2/2019 12:31 PM
Contacts	Authorizing Official	Update	Change Request	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	9/27/2018 7:37 AM
Addresses	Shipping Address	Insert	Recertification		Our Lady of the Lake Outpatient Oncology 4950 Essen Ln Baton Rouge, LA 70809-3738	9/11/2018 7:30 AM
Addresses	Shipping Address	Insert	Recertification		Our Lady of the Lake Livingston 5000 O'Donovan Blvd Walker, LA 70785	9/11/2018 7:30 AM
Details	Last Recertification Date	Update	Recertification	11/29/2017 3:35:32 PM	9/11/2018 7:30:10 AM	9/11/2018 7:30 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/13/2018 4:21 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2202375	4/13/2018 4:21 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	4/13/2018 4:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/13/2018 4:21 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2205641	4/13/2018 4:21 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	4/13/2018 4:21 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1841544194 ( )		4/13/2018 4:21 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1932264363 ( )		4/13/2018 4:21 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1831605062	4/13/2018 4:21 PM
Addresses	Shipping Address	Delete	Change Request	LSU Health Baton Rouge - Mid City Pharmacy 1401 N Foster Drive Baton Rouge, LA 70806		1/17/2018 7:36 AM
Addresses	Shipping Address	Insert	Change Request		Mid City Pharmacy 1401 N Foster Drive Baton Rouge, LA 70806	1/17/2018 7:36 AM
Addresses	Shipping Address	Insert	Change Request		O'Donovan Pharmacy 5131 O'Donovan Drive Suite 402 Baton Rouge, LA 70808	1/17/2018 7:36 AM
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/29/2017 3:35:32 PM	11/29/2017 3:35 PM
Contacts	Primary Contact	Update	Recertification	Mohundro, Michael Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	Mohundro, Michael Marlan Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	11/29/2017 1:49 PM
Addresses	Shipping Address	Delete	Change Request	Medical Plaza Pharmacy 7777 Hennessy Blvd 114 Baton Rouge, LA 70808		10/16/2017 7:57 PM
Addresses	Shipping Address	Delete	Change Request	Our Lady of the Lake Livingston Pharmacy 5000 O'Donovan Blvd 104 Walker, LA 70785		10/16/2017 7:57 PM
Addresses	Shipping Address	Insert	Change Request		Medical Plaza Pharmacy 7777 Hennessy Blvd 114 Baton Rouge, LA 70808	10/16/2017 7:57 PM
Addresses	Shipping Address	Insert	Change Request		Our Lady of the Lake Livingston Pharmacy 5000 O'Donovan Blvd 104 Walker, LA 70785	10/16/2017 7:57 PM
Contacts	Authorizing Official	Update		Limbocker, Jeffrey CFO 2257658550	Limbocker, Jeffrey CFO Our Lady of the Lake 2257658550	10/16/2017 5:56 PM
Contacts	Primary Contact	Update		Mohundro, Michael Senior Director of Pharmacy 2259077045	Mohundro, Michael Senior Director of Pharmacy Our Lady of the Lake RMC 2259077045	10/3/2017 2:20 PM
Contacts	Authorizing Official	Update		RAMSEY Jr., ROBERT D. CFO 2257658967	Limbocker, Jeffrey CFO 2257658550	10/17/2016 12:15 PM
Contacts	Primary Contact	Insert			Mohundro, Michael Senior Director of Pharmacy 2259077045	8/31/2016 12:46 PM
Addresses	Main Address	Insert			5000 HENNESSY BLVD. BATON ROUGE, LA 70808	8/31/2016 12:45 PM
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 12:45 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	9/3/2015 5:02 PM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	9/3/2015 12:00:00 AM	9/3/2015 5:02 PM
Addresses	Shipping Address	Insert			LSU Health Baton Rouge - Surgical Center Pharmacy 9032 Perkins Road Baton Rouge, LA 70810	3/10/2015 1:35 PM
Addresses	Shipping Address	Insert			LSU Health Baton Rouge - Mid City Pharmacy 1401 N Foster Drive Baton Rouge, LA 70806	3/10/2015 1:35 PM
Addresses	Shipping Address	Insert			LSU Health Baton Rouge - North Clinic Pharmacy 5439 Airline Hwy Baton Rouge, LA 70805	3/10/2015 1:35 PM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 12:47 PM
Medicaid Billing	Medicaid: Number	Update		1257885	1720160	12/10/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1366436123	12/10/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1841544194	12/10/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1932264363	12/10/2013 6:47 AM
Medicaid Billing	NPI: Number	Insert			1215365341	12/10/2013 6:47 AM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/13/2013 12:00:00 AM	9/13/2013 6:22 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/29/2012 12:14 PM
Contacts	Authorizing Official	Insert			RAMSEY Jr., ROBERT D. CFO 2257658967	3/12/2008 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	3/4/2008 1:07 PM
Medicaid Billing	Medicaid: Number	Insert			1257885	3/4/2008 1:07 PM
Medicaid Billing	Medicaid: State	Insert			LA	3/4/2008 1:07 PM
Details	Last Recertification Date	Insert				3/4/2008 1:07 PM
Details	Grant Number	Insert				3/4/2008 1:07 PM
Details	340B ID	Insert			DSH190064	3/4/2008 1:07 PM
Details	Is Authorizing Official EHB Data	Insert				3/4/2008 1:07 PM
Dates	Last Date That 340B Drugs Purchased	Insert				3/4/2008 1:07 PM
Details	Medicare Provider Number	Insert			190064	3/4/2008 1:07 PM
Details	Entity Name	Insert			OUR LADY OF THE LAKE HOSPITAL, INC.	3/4/2008 1:07 PM
Details	Program Code	Insert			DSH	3/4/2008 1:07 PM
Details	Entity Subname	Insert				3/4/2008 1:07 PM
Dates	Participating Approval Date	Insert			3/12/2008 12:00:00 AM	3/4/2008 1:07 PM
Details	State	Insert			Active	3/4/2008 1:07 PM
Dates	Registration Date	Insert			3/4/2008 12:00:00 AM	3/4/2008 1:07 PM
Dates	Signed By Date	Insert			2/25/2008 12:00:00 AM	3/4/2008 1:07 PM
Dates	Start Date	Insert			4/1/2008 12:00:00 AM	3/4/2008 1:07 PM
Terminations	Termination Comments	Insert				3/4/2008 1:07 PM
Terminations	Termination Date	Insert				3/4/2008 1:07 PM
Terminations	Termination Effective Date	Insert				3/4/2008 1:07 PM
Terminations	Termination Reason	Insert				3/4/2008 1:07 PM