Covered Entity Details

DSH190064AE OUR LADY OF THE LAKE (Active) - information as of 5/3/2025 11:26:11 PM

Main Details

Name

OUR LADY OF THE LAKE

Subdivision Name

Pediatric Physical Medicine Clinic

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190064AE

Medicare Provider Number

190064

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2013

Participating Start Date

7/1/2013

Participating Approval Date

5/21/2013

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

8415 Goodwood Blvd
Suite 200
Baton Rouge, LA 70806

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	2202375,2207041,1720160,2205641	1740847771,1831605062,1215365341,1366436123

Shipping Addresses

Shipping Address 1

Our Lady of the Lake RMC HSP PHY REG MC PHY HSP Pharmacy
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	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

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
Details	Last Recertification Date	Update	Recertification	9/2/2023 12:16:00 PM	8/15/2024 2:51:38 PM	8/15/2024 2:51 PM
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
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
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
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/7/2023 6:09 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2205641	9/7/2023 6:09 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	9/7/2023 6:09 PM
Contacts	Primary Contact	Update	PC 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	9/5/2023 7:16 AM
Details	Last Recertification Date	Update	Recertification	8/25/2022 1:35:30 PM	9/2/2023 12:16:00 PM	9/2/2023 12:16 PM
Addresses	Shipping Address	Insert	Change Request		Our Lady of the Lake RMC HSP PHY REG MC PHY HSP Pharmacy 5000 Hennessy Blvd Baton Rouge, LA 70808-4375	1/3/2023 10:40 AM
Details	Last Recertification Date	Update	Recertification	8/24/2021 10:18:10 AM	8/25/2022 1:35:30 PM	8/25/2022 1:35 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
Details	Last Recertification Date	Update	Recertification	9/13/2020 5:37:34 PM	8/24/2021 10:18:10 AM	8/24/2021 10:18 AM
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 8:04 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	5/24/2021 4:32 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2202375	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1938589	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		2207041	9/13/2020 5:37 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1740847771	9/13/2020 5:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1831605062	9/13/2020 5:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1215365341	9/13/2020 5:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1366436123	9/13/2020 5:37 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	9/13/2020 5:37 PM
Details	Last Recertification Date	Update	Recertification	9/16/2019 5:02:47 PM	9/13/2020 5:37:34 PM	9/13/2020 5:37 PM
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
Details	Last Recertification Date	Update	Recertification	9/10/2018 4:53:26 PM	9/16/2019 5:02:47 PM	9/16/2019 5:02 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
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
Details	Last Recertification Date	Update	Recertification	11/13/2017 1:26:02 PM	9/10/2018 4:53:26 PM	9/10/2018 4:53 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
Details	Last Recertification Date	Update	Recertification	8/31/2016 12:00:00 AM	11/13/2017 1:26:02 PM	11/13/2017 1:26 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	Signed By	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	Insert			Limbocker, Jeffrey CFO 2257658550	10/17/2016 12:15 PM
Contacts	Signed By	Insert			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
Details	Last Recertification Date	Update		9/3/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 12:46 PM
Addresses	Main Address	Insert			8415 Goodwood Blvd Suite 200 Baton Rouge, LA 70806	8/31/2016 12:45 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
Medicaid Billing	Medicaid: Is Primary	Insert			False	9/3/2014 12:48 PM
Medicaid Billing	Medicaid: Number	Insert			1720160	9/3/2014 12:48 PM
Medicaid Billing	Medicaid: State	Insert			LA	9/3/2014 12:48 PM
Details	Last Recertification Date	Update		9/13/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 12:48 PM
Details	Last Recertification Date	Update			9/13/2013 12:00:00 AM	9/13/2013 6:22 AM
Details	340B ID	Update		ISAPDSH190064AE	DSH190064AE	5/21/2013 12:46 PM
Dates	Participating Approval Date	Update			5/21/2013 12:00:00 AM	5/21/2013 12:46 PM
Details	State	Update		Pending	Active	5/21/2013 12:46 PM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	5/21/2013 12:46 PM
Details	340B ID	Update		ISAPDSH190064AH	ISAPDSH190064AE	5/20/2013 3:32 PM
Details	340B ID	Update		ISPAPDSH190064AH	ISAPDSH190064AH	4/22/2013 8:26 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	ISPAPDSH190064AH	4/22/2013 8:17 AM
Details	Last Recertification Date	Insert				4/12/2013 12:56 PM
Details	Grant Number	Insert				4/12/2013 12:56 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/12/2013 12:56 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2013 12:56 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2013 12:56 PM
Details	Medicare Provider Number	Insert			190064	4/12/2013 12:56 PM
Details	Entity Name	Insert			OUR LADY OF THE LAKE HOSPITAL, INC.	4/12/2013 12:56 PM
Details	Program Code	Insert			DSH	4/12/2013 12:56 PM
Details	Entity Subname	Insert			Pediatric Physical Medicine Clinic	4/12/2013 12:56 PM
Dates	Participating Approval Date	Insert				4/12/2013 12:56 PM
Details	State	Insert			Pending	4/12/2013 12:56 PM
Dates	Registration Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 12:56 PM
Dates	Signed By Date	Insert			4/12/2013 12:00:00 AM	4/12/2013 12:56 PM
Dates	Start Date	Insert				4/12/2013 12:56 PM
Terminations	Termination Comments	Insert				4/12/2013 12:56 PM
Terminations	Termination Date	Insert				4/12/2013 12:56 PM
Terminations	Termination Effective Date	Insert				4/12/2013 12:56 PM
Terminations	Termination Reason	Insert				4/12/2013 12:56 PM