Covered Entity Details

DSH190102AG OUR LADY OF LOURDES RMC (Active) - information as of 6/7/2025 4:39:26 AM

Main Details

Name

OUR LADY OF LOURDES RMC

Subdivision Name

HEART HOSPITAL PHYSICAL THERAPY - HHL PT

Type

Disproportionate Share Hospital

Rural

340B ID

DSH190102AG

Medicare Provider Number

190102

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/14/2020

Participating Start Date

1/1/2021

Participating Approval Date

10/27/2020

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Our Lady of Lourdes Health
Jeremy Rogers, VP, Chief Financial Officer
(337) 470-2147

Primary Contact

Our Lady of Lourdes Regional Medical Center
Stacy Boatright, Director of Pharmacy
(337) 470-2111

Addresses

Street Address

1105 KALISTE SALOOM RD
LAFAYETTE, LA 70508-5705

Billing Address

FMOLHS ACCOUNTS PAYABLE
PO BOX 83880
BATON ROUGE, LA 70884-3880

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	1720445	1598766495

Shipping Addresses

Same as Street Address

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
DSH190102A	Child	DSH	OUR LADY OF LOURDES RMC	OUR LADY OF LOURDES REGIONAL MEDICA - Woundcare Center	4809 AMBASSADOR CAFFERY PKWY, STE 390	LAFAYETTE	LA	Active
DSH190102AA	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S REHAB SERVICE - REHAB SERVICES	4630 AMBASSADOR CAFFERY PKWY.	LAFAYETTE	LA	Active
DSH190102AB	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL CATH LAB - HHL CATH LAB	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AC	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL COUMADIN SERVICES- HHL COUMADIN LAFAYETTE	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AD	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL COUMADIN CLINC - Heart Hospital Coumadin Clinic Abbeville	2621 NORTH DR. (Lahasky Medical Building)	ABBEVILLE	LA	Active
DSH190102AE	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL SMOKING CESSATION PROGRAM - SMOKING CESSATION	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AF	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL RESPIRATORY THERAPY - HHL RESPIRATORY THERAPY	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AG	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL PHYSICAL THERAPY - HHL PT	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AH	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL SPEECH THERAPY - HHL SPEECH	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AJ	Child	DSH	OUR LADY OF LOURDES RMC	OUR LADY OF LOURDES ED - SCOTT - SCOTT ER	662 I-10 North Frontage Road	SCOTT	LA	Active
DSH190102AK	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL LABORATORY - HHL LAB	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AL	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL IMAGING	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AM	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL CAT SCAN - HHL CT	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AN	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL DAY PATIENT - HHL DAY PATIENT	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AP	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL CARDIAC REHAB - HHL CARDIAC REHAB	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AQ	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL OPERATING ROOM - HEART OR	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AR	Child	DSH	OUR LADY OF LOURDES RMC	HEART HOSPITAL EMERGENCY ROOM - HHL ER	1105 KALISTE SALOOM RD	LAFAYETTE	LA	Active
DSH190102AS	Child	DSH	OUR LADY OF LOURDES RMC	Lourdes Breast Center - Imaging Services	2311 KALISTE SALOOM ROAD	Lafayette	LA	Active
DSH190102AT	Child	DSH	OUR LADY OF LOURDES RMC	LOURDES SLEEP DISORDER CENTER - Sleep Center	100 ASMA BLVD	Lafayette	LA	Active
DSH190102AU	Child	DSH	OUR LADY OF LOURDES RMC	LOURDES SLEEP DISORDER CENTER AT CROWLEY - Sleep Center-Crowley	1325 WRIGHT AVE STE 1	CROWLEY	LA	Terminated
DSH190102AV	Child	DSH	OUR LADY OF LOURDES RMC	LOURDES ST. MARY IMAGING - Imaging Services	411 St. Landry Street	LAFAYETTE	LA	Active
DSH190102AW	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN'S GENETICS - LAFAYETTE - GENETICS SERVICES	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 202	LAFAYETTE	LA	Active
DSH190102AX	Child	DSH	OUR LADY OF LOURDES RMC	Women's and Children's Emergency Department - Emergency Services	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102AY	Child	DSH	OUR LADY OF LOURDES RMC	WCH ANESTHESIA - ANESTHESIA SERVICES	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102AZ	Child	DSH	OUR LADY OF LOURDES RMC	OLOL Children's Endocrinology - Endocrinology services	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 203	LAFAYETTE	LA	Active
DSH190102B	Child	DSH	OUR LADY OF LOURDES RMC	JD MONCUS CANCER CENTER - Outpatient Infusion	4809 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102BA	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN'S GENERAL SURGERY - LAFAYETTE - GENERAL SURGERY	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 200	LAFAYETTE	LA	Active
DSH190102BB	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN'S NEUROLOGY - LAFAYETTE - NEUROLOGY SERVICES	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 201	LAFAYETTE	LA	Active
DSH190102BC	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN'S NEUROSURGERY - LAFAYETTE - NEUROSURGERY	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 204	LAFAYETTE	LA	Active
DSH190102BD	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN ORTHOPEDIC - LAFAYETTE - ORTHOPEDIC SERVICES	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 100	LAFAYETTE	LA	Active
DSH190102BE	Child	DSH	OUR LADY OF LOURDES RMC	OLOL CHILDREN'S PULMONOLOGY - LAFAYETTE - PULMONOLOGY SERVICES	4704 AMBASSADOR CAFFERY PKWY BUILDING E STE 300A	LAFAYETTE	LA	Active
DSH190102BF	Child	DSH	OUR LADY OF LOURDES RMC	Heart Hospital Coumadin Services Scott - Coumadin Clinic-Scott	662 I-10 N Frontage	SCOTT	LA	Active
DSH190102BG	Child	DSH	OUR LADY OF LOURDES RMC	Lourdes WCH EEG - WCH EEG	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102C	Child	DSH	OUR LADY OF LOURDES RMC	JD MONCUS CANCER CENTER - Cancer Clinic	4809 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102D	Child	DSH	OUR LADY OF LOURDES RMC	LOURDES IMAGING CTR - ACC - Lourdes Imaging Center-ACC	4809 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102E	Child	DSH	OUR LADY OF LOURDES RMC	WCH AUDIOLOGY - WCH AUDIOLOGY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102F	Child	DSH	OUR LADY OF LOURDES RMC	WCH KIDS RADIOLOGY - WCH KIDS RADIOLOGY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Terminated
DSH190102G	Child	DSH	OUR LADY OF LOURDES RMC	WCH PHYSICAL THERAPY - WCH PHYSICAL THERAPY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102H	Child	DSH	OUR LADY OF LOURDES RMC	WCH LABOR & DELIVERY - WCH LABOR & DELIVERY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102J	Child	DSH	OUR LADY OF LOURDES RMC	WCH OCCUPATIONAL THERAPY - WCH OCCUPATIONAL THERAPY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Terminated
DSH190102K	Child	DSH	OUR LADY OF LOURDES RMC	WCH US IMAGING	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102L	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S SPECIAL PROCEDURE - WCH SPECIAL PROCEDURE	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102M	Child	DSH	OUR LADY OF LOURDES RMC	WCH BLOOD BANK - WCH BLOOD BANK	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102N	Child	DSH	OUR LADY OF LOURDES RMC	WCH CANCER AND INFUSION CENTER - Children's Infusion	4704 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102P	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S NUCLEAR MEDICINE - WCH NUCLEAR MEDICINE	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102Q	Child	DSH	OUR LADY OF LOURDES RMC	WCH XR IMAGING	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102R	Child	DSH	OUR LADY OF LOURDES RMC	WCH CT IMAGING - WCH CT IMAGING	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102S	Child	DSH	OUR LADY OF LOURDES RMC	WCH DAY OPERATING SURGERY - WCH DAY OPERATING SURGERY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102T	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S SURGERY - WCH SURGERY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102U	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S RECOVERY - WCH RECOVERY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102V	Child	DSH	OUR LADY OF LOURDES RMC	WCH PATHOLOGY - WCH PATHOLOGY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102W	Child	DSH	OUR LADY OF LOURDES RMC	WCH RESPIRATORY - WCH RESPIRATORY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102X	Child	DSH	OUR LADY OF LOURDES RMC	WCH MRI - WCH MRI	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102Y	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDREN'S LABORATORY - WOMEN'S AND CHILDREN'S LABORATORY	4600 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active
DSH190102Z	Child	DSH	OUR LADY OF LOURDES RMC	WOMEN'S AND CHILDRENS SLEEP LAB - SLEEP LAB	4630 AMBASSADOR CAFFERY PKWY	LAFAYETTE	LA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/11/2023 9:32:45 AM	8/13/2024 11:33:52 AM	8/13/2024 11:33 AM
Contacts	Authorizing Official	Update	Profile Change Request	Rogers, Jeremy Chief Operating Officer/Chief Financial Officer St. Francis Medical Center 3189667212	Rogers, Jeremy VP, Chief Financial Officer Our Lady of Lourdes Health 3374702147	4/30/2024 7:27 AM
Contacts	Authorizing Official	Update	Change Request	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lourdes Medical Center 3374702147	Rogers, Jeremy Chief Operating Officer/Chief Financial Officer St. Francis Medical Center 3189667212	4/29/2024 7:51 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 12:16:35 PM	9/11/2023 9:32:45 AM	9/11/2023 9:32 AM
Addresses	Billing Address	Update	Change Request	FMOLHS ACCOUNTS PAYABLE PO BOX 83880 BATON ROUGE, LA 70884	FMOLHS ACCOUNTS PAYABLE PO BOX 83880 BATON ROUGE, LA 70884-3880	4/27/2023 9:12 AM
Contacts	Authorizing Official	Update	Profile Change Request	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lourdes Medical Center 3374702147	10/3/2022 4:09 PM
Contacts	Authorizing Official	Update	AO Change Request	Kiser, Crystal R Manager Our Lady of Lourdes Regional Medical Center 3374702131	Stanton, Lowell Edward Chief Financial Officer Our Lady of the Lake Regional Medical Center 2257658550	8/30/2022 7:38 AM
Details	Last Recertification Date	Update	Recertification	8/17/2021 10:50:49 AM	8/29/2022 12:16:35 PM	8/29/2022 12:16 PM
Contacts	Primary Contact	Update	Group Change Request	Broussard, Edward L Director of Pharmacy Our Lady of Lourdes Regional Medical Center 3374702111-3374702131	Boatright, Stacy Director of Pharmacy Our Lady of Lourdes Regional Medical Center 3374702111	7/12/2022 8:42 AM
Addresses	Billing Address	Update	Change Request	OUR LADY OF LOURDES HEART HOSPITAL 1105 KALISTE SALOOM ROAD LAFAYETTE, LA 70508-5705	FMOLHS ACCOUNTS PAYABLE PO BOX 83880 BATON ROUGE, LA 70884	1/4/2022 9:02 AM
Addresses	Billing Address	Update	Change Request	OUR LADY OF LOURDES REGIONAL MEDICAL CENTER 4801 AMBASSADOR CAFFERY PKWY LAFAYETTE, LA 70508-6917	OUR LADY OF LOURDES HEART HOSPITAL 1105 KALISTE SALOOM ROAD LAFAYETTE, LA 70508-5705	10/22/2021 2:43 PM
Details	Last Recertification Date	Update	Recertification		8/17/2021 10:50:49 AM	8/17/2021 10:50 AM
Addresses	Main Address	Update	Change Request	1105 KALISTE SALOOM LAFAYETTE, LA 70508-5705	1105 KALISTE SALOOM RD LAFAYETTE, LA 70508-5705	7/16/2021 12:41 PM
Details	State	Update		Approved	Active	1/1/2021 12:01 AM
Contacts	Signed By	Insert	New Registration		Kiser, Crystal R Manager Our Lady of Lourdes Regional Medical Center 3374702131	10/27/2020 7:50 AM
Details	340B ID	Update	New Registration		DSH190102AG	10/27/2020 7:50 AM
Details	Entity Subname	Update	New Registration	HEART HOSPITAL PHYSICAL THERAPY	HEART HOSPITAL PHYSICAL THERAPY - HHL PT	10/27/2020 7:50 AM
Dates	Participating Approval Date	Update	New Registration		10/27/2020 7:50:41 AM	10/27/2020 7:50 AM
Details	State	Update	New Registration	Pending	Approved	10/27/2020 7:50 AM
Dates	Signed By Date	Update	New Registration		10/22/2020 2:36:16 PM	10/27/2020 7:50 AM
Dates	Start Date	Update	New Registration		1/1/2021 12:00:00 AM	10/27/2020 7:50 AM
Addresses	Main Address	Insert	New Registration		1105 KALISTE SALOOM LAFAYETTE, LA 70508-5705	10/14/2020 3:36 PM
Addresses	Billing Address	Insert	New Registration		OUR LADY OF LOURDES REGIONAL MEDICAL CENTER 4801 AMBASSADOR CAFFERY PKWY LAFAYETTE, LA 70508-6917	10/14/2020 3:36 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2020 3:36 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1720445	10/14/2020 3:36 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		LA	10/14/2020 3:36 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1598766495	10/14/2020 3:36 PM
Medicaid Billing	NPI: State	Insert	New Registration		LA	10/14/2020 3:36 PM
Contacts	Authorizing Official	Insert	New Registration		Kiser, Crystal R Manager Our Lady of Lourdes Regional Medical Center 3374702131	10/14/2020 3:36 PM
Contacts	Primary Contact	Insert	New Registration		Broussard, Edward L Director of Pharmacy Our Lady of Lourdes Regional Medical Center 3374702111-3374702131	10/14/2020 3:36 PM
Details	Assistance Received From Date	Insert	New Registration			10/14/2020 3:36 PM
Details	Assistance Received To Date	Insert	New Registration			10/14/2020 3:36 PM
Details	Last Recertification Date	Insert	New Registration			10/14/2020 3:36 PM
Details	Grant Number	Insert	New Registration			10/14/2020 3:36 PM
Details	340B ID	Insert	New Registration			10/14/2020 3:36 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2020 3:36 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2020 3:36 PM
Details	Medicare Provider Number	Insert	New Registration		190102	10/14/2020 3:36 PM
Details	Entity Name	Insert	New Registration		OUR LADY OF LOURDES RMC	10/14/2020 3:36 PM
Details	NOFO Number	Insert	New Registration			10/14/2020 3:36 PM
Details	Program Code	Insert	New Registration		DSH	10/14/2020 3:36 PM
Details	Entity Subname	Insert	New Registration		HEART HOSPITAL PHYSICAL THERAPY	10/14/2020 3:36 PM
Dates	Participating Approval Date	Insert	New Registration			10/14/2020 3:36 PM
Details	State	Insert	New Registration		Pending	10/14/2020 3:36 PM
Dates	Registration Date	Insert	New Registration		10/14/2020 3:36:52 PM	10/14/2020 3:36 PM
Dates	Signed By Date	Insert	New Registration			10/14/2020 3:36 PM
Dates	Start Date	Insert	New Registration			10/14/2020 3:36 PM
Terminations	Termination Comments	Insert	New Registration			10/14/2020 3:36 PM
Terminations	Termination Date	Insert	New Registration			10/14/2020 3:36 PM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2020 3:36 PM
Terminations	Termination Reason	Insert	New Registration			10/14/2020 3:36 PM