Covered Entity Details

DSH190060N Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital (Active) - information as of 6/8/2025 11:58:02 PM

Main Details

Name

Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital

Subdivision Name

Iowa Rural Clinic

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH190060N

Medicare Provider Number

190060

Outpatient Facility Provider Number

190060

Additional Details

Current Program Status

Active

Registration Date

7/14/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/12/2013

Last Recertification Date

8/16/2024

Contacts

Authorizing Official

Lake Charles Memorial Hospital
Devon Hyde, President/CEO
(337) 494-3200

Primary Contact

Lake Charles Memorial Hospital
Julia Manuel, Health-System Director of Pharmacy
(337) 494-3182

Addresses

Street Address

203 East Miller Avenue Suite B
Iowa, LA 70647

Billing Address

Lake Charles Memorial Hospital
1701 Oak Park Blvd
Lake Charles, LA 70601

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	1720461,2204670,2209442	1972549855,1922150564,1407910631,1679637805,1134271497,1881349777

Shipping Addresses

Shipping Address 1

Lake Charles Memorial Hospital
1701 Oak Park Blvd
Lake Charles, LA 70601

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
DSH190060A	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	LAKE CHARLES MEMORIAL HOSPITAL FOR WOMEN	1900 W. GAUTHIER ROAD	LAKE CHARLES	LA	Active
DSH190060B	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	OB Care of Lake Charles	1890 W. Gauthier Road	Lake Charles	LA	Active
DSH190060C	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	W.O. Moss Memorial Health Clinic- Urgent Care Clinic	1000 Walters Street	Lake Charles	LA	ToBeTerminated
DSH190060D	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Minor Procedure Clinic	1000 Walters Street	Lake Charles	LA	Active
DSH190060E	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Gyn Clinic	1701 Oak Park Blvd	Lake Charles	LA	Active
DSH190060F	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Outpatient Specialty Clinic	1000 Walters Street	Lake Charles	LA	Active
DSH190060G	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Primary Care Clinic	1000 Walters Street	Lake Charles	LA	Active
DSH190060J	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Comprehensive Care Clinic	1000 Walters Street	Lake Charles	LA	Active
DSH190060K	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	W.O. Moss Memorial Health Clinic- Radiology/Diagnostics	1000 Walters Street	Lake Charles	LA	ToBeTerminated
DSH190060L	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	W.O. Moss Memorial Health Clinic- Electrocardiology	1000 Walters Street	Lake Charles	LA	ToBeTerminated
DSH190060M	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Lake Charles Memorial Hospital Wound Care Center	1801 Oak Park Boulevard	Lake Charles	LA	Active
DSH190060N	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Iowa Rural Clinic	203 East Miller Avenue Suite B	Iowa	LA	Active
DSH190060P	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Lake Charles Memorial Hospital for Women-Radiology	1900 West Gauthier Road	Lake Charles	LA	Active
DSH190060Q	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Lake Charles Memorial Hospital for Women-Surgery	1900 West Gauthier Road	Lake Charles	LA	Active
DSH190060R	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Lake Charles Memorial Hospital for Women-Recovery Room	1900 West Gauthier Road	Lake Charles	LA	Active
DSH190060S	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Lake Charles Memorial Hospital for Women-Lab	1900 West Gauthier Road	Lake Charles	LA	ToBeTerminated
DSH190060T	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Moss Cardiac Clinic	1000 WALTERS ST	LAKE CHARLES	LA	Active
DSH190060U	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	LAKE CHARLES MEMORIAL HOSPITAL OUTP - INTENSE PSYCH	1000 Walter Street	LAKE CHARLES	LA	Active
DSH190060V	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	Rheumatology Clinic - Rheumatology	2800 2nd Avenue Suite C	Lake Charles	LA	Active
DSH190060W	Child	DSH	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	DIGESTIVE HEALTH CENTER OF SWLA - Gastroenterology	2770 3RD AVE	LAKE CHARLES	LA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Billing Address	Insert	Change Request		Lake Charles Memorial Hospital 1701 Oak Park Blvd Lake Charles, LA 70601	6/6/2025 7:00 AM
Addresses	Main Address	Update	Change Request	203 East Miller Avenue Iowa, LA 70647	203 East Miller Avenue Suite B Iowa, LA 70647	6/6/2025 7:00 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	5/16/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2209442	5/16/2025 3:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	5/16/2025 3:30 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1881349777	5/16/2025 3:30 PM
Medicaid Billing	NPI: State	Insert	Change Request		LA	5/16/2025 3:30 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	910286800 (FL)		10/9/2024 12:06 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	190060 (TN)		10/9/2024 12:06 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	130043603 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134271497 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1407910631 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679637805 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1922150564 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1972549855 (TX)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134271497 (TN)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1407910631 (TN)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679637805 (TN)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1922150564 (TN)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1972549855 (TN)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134271497 (FL)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1407910631 (FL)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679637805 (FL)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1922150564 (FL)		10/9/2024 12:06 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1972549855 (FL)		10/9/2024 12:06 PM
Details	Last Recertification Date	Update	Recertification	8/28/2023 1:36:20 PM	8/16/2024 5:28:28 PM	8/16/2024 5:28 PM
Addresses	Shipping Address	Insert	Change Request		Lake Charles Memorial Hospital 1701 Oak Park Blvd Lake Charles, LA 70601	7/11/2024 7:41 AM
Details	Last Recertification Date	Update	Recertification	9/7/2022 9:50:29 AM	8/28/2023 1:36:20 PM	8/28/2023 1:36 PM
Details	Last Recertification Date	Update	Recertification	9/9/2021 11:05:21 AM	9/7/2022 9:50:29 AM	9/7/2022 9:50 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134271497	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407910631	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679637805	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922150564	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1972549855	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TX	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134271497	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407910631	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679637805	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922150564	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1972549855	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1134271497	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1407910631	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679637805	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1922150564	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2021 11:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1972549855	9/9/2021 11:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/9/2021 11:05 AM
Details	Last Recertification Date	Update	Recertification	8/26/2020 4:16:55 PM	9/9/2021 11:05:21 AM	9/9/2021 11:05 AM
Contacts	Authorizing Official	Update	Change Request	WHITSON, CHARLES CFO Lake Charles Memorial Hospital 3374943204	Hyde, Devon President/CEO Lake Charles Memorial Hospital 3374943200	4/30/2021 7:04 AM
Medicaid Billing	NPI: State	Update	Recertification		LA	8/26/2020 4:16 PM
Medicaid Billing	NPI: State	Update	Recertification		LA	8/26/2020 4:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1407910631	8/26/2020 4:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/26/2020 4:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1679637805	8/26/2020 4:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/26/2020 4:16 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1134271497	8/26/2020 4:16 PM
Medicaid Billing	NPI: State	Insert	Recertification		LA	8/26/2020 4:16 PM
Details	Last Recertification Date	Update	Recertification	9/5/2019 2:10:03 PM	8/26/2020 4:16:55 PM	8/26/2020 4:16 PM
Details	Last Recertification Date	Update	Recertification	8/17/2018 3:07:50 PM	9/5/2019 2:10:03 PM	9/5/2019 2:10 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1720461	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		2204670	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		LA	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		910286800	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		190060	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TN	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		130043603	8/1/2019 11:19 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	8/1/2019 11:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1972549855	8/1/2019 11:19 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922150564	8/1/2019 11:19 AM
Details	Entity Name	Update	Change Request	LAKE CHARLES MEMORIAL HOSPITAL	Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital	11/13/2018 7:58 AM
Details	Last Recertification Date	Update	Recertification	11/6/2017 10:10:36 AM	8/17/2018 3:07:50 PM	8/17/2018 3:07 PM
Contacts	Primary Contact	Update	Recertification	Manuel, Julia Health-System Director of Pharmacy 3374943182	Manuel, Julia Health-System Director of Pharmacy Lake Charles Memorial Hospital 3374943182	11/6/2017 10:10 AM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/6/2017 10:10:36 AM	11/6/2017 10:10 AM
Contacts	Authorizing Official	Update		WHITSON, CHARLES CFO 3374943204	WHITSON, CHARLES CFO Lake Charles Memorial Hospital 3374943204	10/16/2017 2:25 PM
Contacts	Signed By	Update		WHITSON, CHARLES CFO 3374943204	WHITSON, CHARLES CFO Lake Charles Memorial Hospital 3374943204	10/16/2017 2:25 PM
Contacts	Authorizing Official	Insert			WHITSON, CHARLES CFO 3374943204	7/24/2017 2:02 PM
Contacts	Signed By	Insert			WHITSON, CHARLES CFO 3374943204	7/24/2017 2:02 PM
Addresses	Main Address	Insert			203 East Miller Avenue Iowa, LA 70647	3/31/2017 10:06 AM
Contacts	Primary Contact	Insert			Manuel, Julia Health-System Director of Pharmacy 3374943182	3/31/2017 10:06 AM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 4:17 PM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/7/2015 12:00:00 AM	8/7/2015 1:03 PM
Details	Last Recertification Date	Update			8/26/2014 12:00:00 AM	8/26/2014 1:29 PM
Details	340B ID	Update		ISJMDSH190060N	DSH190060N	9/12/2013 10:38 AM
Dates	Participating Approval Date	Update			9/12/2013 12:00:00 AM	9/12/2013 10:38 AM
Details	State	Update		Pending	Active	9/12/2013 10:38 AM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/12/2013 10:38 AM
Details	340B ID	Update		JMDSH190060N	ISJMDSH190060N	8/6/2013 3:57 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	JMDSH190060N	8/3/2013 9:28 AM
Details	Last Recertification Date	Insert				7/14/2013 9:48 PM
Details	Grant Number	Insert				7/14/2013 9:48 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/14/2013 9:48 PM
Details	Is Authorizing Official EHB Data	Insert				7/14/2013 9:48 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/14/2013 9:48 PM
Details	Medicare Provider Number	Insert			190060	7/14/2013 9:48 PM
Details	Entity Name	Insert			LAKE CHARLES MEMORIAL HOSPITAL	7/14/2013 9:48 PM
Details	Program Code	Insert			DSH	7/14/2013 9:48 PM
Details	Entity Subname	Insert			Iowa Rural Clinic	7/14/2013 9:48 PM
Dates	Participating Approval Date	Insert				7/14/2013 9:48 PM
Details	State	Insert			Pending	7/14/2013 9:48 PM
Dates	Registration Date	Insert			7/14/2013 12:00:00 AM	7/14/2013 9:48 PM
Dates	Signed By Date	Insert			7/14/2013 12:00:00 AM	7/14/2013 9:48 PM
Dates	Start Date	Insert				7/14/2013 9:48 PM
Terminations	Termination Comments	Insert				7/14/2013 9:48 PM
Terminations	Termination Date	Insert				7/14/2013 9:48 PM
Terminations	Termination Effective Date	Insert				7/14/2013 9:48 PM
Terminations	Termination Reason	Insert				7/14/2013 9:48 PM