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BRIOVARX OF MAINE INC
CAH191323-01 Hospital Service District 1A, Parish of Richland, State of Louisiana, DBA Richland Parish Hospital
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Covered Entity Details
Entity Name
Hospital Service District 1A, Parish of Richland, State of Louisiana, DBA Richland Parish Hospital
Subdivision Name
Delhi Rural Health Clinic
Type
Critical Access Hospital
340B ID
CAH191323-01
Entity Address
508 Broadway Street
Delhi, LA 71232
Medicare Provider Number
191323
Outpatient Facility Provider Number
193417
Participating Start Date
7/1/2014
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/4/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Michael Carroll, CEO
(318) 878-6323
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/10/2018
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