Covered Entity Details

DSH190050C BEAUREGARD MEMORIAL HOSPITAL INC. (Active) - information as of 4/25/2025 6:32:15 PM

Main Details

Name

BEAUREGARD MEMORIAL HOSPITAL INC.

Subdivision Name

Beauregard Family Medical Center - Beauregard Family Medical Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH190050C

Medicare Provider Number

190050

Outpatient Facility Provider Number

198500

Additional Details

Current Program Status

Active

Registration Date

10/8/2021

Participating Start Date

1/1/2022

Participating Approval Date

11/18/2021

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Beauregard Health System
Jarred Veillon, Chief Financial Officer
(337) 462-7495

Primary Contact

Beauregard Memorial Hospital
Alex Manitzas, Director of Pharmacy
(337) 462-7355

Addresses

Street Address

501 South Pine St.
DeRidder, LA 70634

Billing Address
Same as Street Address

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?
No

Shipping Addresses

Shipping Address 1

Beauregard Family Medical Center
600 South Pine St.
DeRidder, LA 70634

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
DSH190050A	Child	DSH	BEAUREGARD MEMORIAL HOSPITAL INC.	Beauregard Women's Health Center - Beauregard Women's Health Center	206 West 5th St	DeRidder	LA	Active
DSH190050B	Child	DSH	BEAUREGARD MEMORIAL HOSPITAL INC.	Beauregard Internal Medicine Center - Beauregard Internal Medicine Center	495 West 8th St.	DeRidder	LA	Active
DSH190050C	Child	DSH	BEAUREGARD MEMORIAL HOSPITAL INC.	Beauregard Family Medical Center - Beauregard Family Medical Center	501 South Pine St.	DeRidder	LA	Active
DSH190050D	Child	DSH	BEAUREGARD MEMORIAL HOSPITAL INC.	Beauregard Medical and Surgical Center - Beauregard Medical and Surgical Center	301 South Washington Avenue	DeRidder	LA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/25/2023 2:34:40 PM	8/14/2024 10:03:26 AM	8/14/2024 10:03 AM
Details	Last Recertification Date	Update	Recertification	8/24/2022 10:00:54 AM	8/25/2023 2:34:40 PM	8/25/2023 2:34 PM
Contacts	Authorizing Official	Update	Profile Change Request	Veillon, Jarred Assistant Vice President of Finance Beauregard Health System 3374627495	Veillon, Jarred Chief Financial Officer Beauregard Health System 3374627495	5/5/2023 7:04 AM
Contacts	Signed By	Update	Profile Change Request	Veillon, Jarred Assistant Vice President of Finance Beauregard Health System 3374627495	Veillon, Jarred Chief Financial Officer Beauregard Health System 3374627495	5/5/2023 7:04 AM
Details	Last Recertification Date	Update	Recertification		8/24/2022 10:00:54 AM	8/24/2022 10:00 AM
Details	State	Update		Approved	Active	1/1/2022 12:01 AM
Contacts	Signed By	Insert	New Registration		Veillon, Jarred Assistant Vice President of Finance Beauregard Health System 3374627495	11/18/2021 2:42 PM
Details	340B ID	Update	New Registration		DSH190050C	11/18/2021 2:42 PM
Details	Entity Subname	Update	New Registration	Beauregard Family Medical Center	Beauregard Family Medical Center - Beauregard Family Medical Center	11/18/2021 2:42 PM
Dates	Participating Approval Date	Update	New Registration		11/18/2021 2:42:39 PM	11/18/2021 2:42 PM
Details	State	Update	New Registration	Pending	Approved	11/18/2021 2:42 PM
Dates	Signed By Date	Update	New Registration		11/17/2021 2:09:18 PM	11/18/2021 2:42 PM
Dates	Start Date	Update	New Registration		1/1/2022 12:00:00 AM	11/18/2021 2:42 PM
Addresses	Main Address	Insert	New Registration		501 South Pine St. DeRidder, LA 70634	10/8/2021 9:54 AM
Addresses	Shipping Address	Insert	New Registration		Beauregard Family Medical Center 600 South Pine St. DeRidder, LA 70634	10/8/2021 9:54 AM
Contacts	Primary Contact	Insert	New Registration		Manitzas, Alex Director of Pharmacy Beauregard Memorial Hospital 3374627355	10/8/2021 9:54 AM
Contacts	Authorizing Official	Insert	New Registration		Veillon, Jarred Assistant Vice President of Finance Beauregard Health System 3374627495	10/8/2021 9:54 AM
Details	Assistance Received From Date	Insert	New Registration			10/8/2021 9:54 AM
Details	Assistance Received To Date	Insert	New Registration			10/8/2021 9:54 AM
Details	Last Recertification Date	Insert	New Registration			10/8/2021 9:54 AM
Details	Grant Number	Insert	New Registration			10/8/2021 9:54 AM
Details	340B ID	Insert	New Registration			10/8/2021 9:54 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2021 9:54 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2021 9:54 AM
Details	Medicare Provider Number	Insert	New Registration		190050	10/8/2021 9:54 AM
Details	Entity Name	Insert	New Registration		BEAUREGARD MEMORIAL HOSPITAL INC.	10/8/2021 9:54 AM
Details	NOFO Number	Insert	New Registration			10/8/2021 9:54 AM
Details	Program Code	Insert	New Registration		DSH	10/8/2021 9:54 AM
Details	Entity Subname	Insert	New Registration		Beauregard Family Medical Center	10/8/2021 9:54 AM
Dates	Participating Approval Date	Insert	New Registration			10/8/2021 9:54 AM
Details	State	Insert	New Registration		Pending	10/8/2021 9:54 AM
Dates	Registration Date	Insert	New Registration		10/8/2021 9:54:47 AM	10/8/2021 9:54 AM
Dates	Signed By Date	Insert	New Registration			10/8/2021 9:54 AM
Dates	Start Date	Insert	New Registration			10/8/2021 9:54 AM
Terminations	Termination Comments	Insert	New Registration			10/8/2021 9:54 AM
Terminations	Termination Date	Insert	New Registration			10/8/2021 9:54 AM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2021 9:54 AM
Terminations	Termination Reason	Insert	New Registration			10/8/2021 9:54 AM