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DSH190064W OUR LADY OF THE LAKE HOSPITAL, INC. (Terminated)
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Main Details
Name
OUR LADY OF THE LAKE HOSPITAL, INC.
Subdivision Name
Our Lady of the Lake Outpatient Infusion at Picardy
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH190064W
Medicare Provider Number
190064
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/12/2013
Participating Start Date
7/1/2013
Participating Approval Date
5/21/2013
Last Recertification Date
8/31/2016
Termination Date
Termination Reason
1/1/2018
Site closure
Contacts
Authorizing Official
Our Lady of the Lourdes Medical Center
Lowell Edward Stanton, Chief Financial Officer
(337) 470-2147
Primary Contact
Our Lady of the Lake RMC
Michael Marlan Mohundro, Senior Director of Pharmacy
(225) 907-7045
Addresses
Street Address
8119 Picardy Avenue
Baton Rouge, LA 70809
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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