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DSH190111BU WILLIS KNIGHTON MEDICAL CENTER, INC. (Active)
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Main Details
Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
W.K. PIERREMONT HEALTH CENTER - ULTRASOUND
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH190111BU
Medicare Provider Number
190111
Outpatient Facility Provider Number
Additional Details
Current Program Status
Active
Registration Date
10/13/2020
Participating Start Date
1/1/2021
Participating Approval Date
10/15/2020
Last Recertification Date
8/17/2024
Contacts
Authorizing Official
Willis-Knighton Medical Center
Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384
Primary Contact
Willis-Knighton Medical Center
TESSA ALBRITTON, DIV. DIRECTOR OF PHARMACY
(318) 212-4039
Addresses
Street Address
8001 YOUREE DR
SHREVEPORT, LA 71115
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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Participating from effective date: (4/1/2017) until terminated effective date: (07/01/2019), reinstatement effective date: (01/01/2021)
10/15/2020
April 2025
April 2025
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