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AVITA PHARMACY 1040
CAH191315-00 HARDTNER MEDICAL CENTER
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Covered Entity Details
Entity Name
HARDTNER MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191315-00
Entity Address
1102 N. PINE ROAD
OLLA, LA 71465
Medicare Provider Number
191315
Participating Start Date
4/1/2015
Last Recertification Date
9/24/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
7/13/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul G. Mathews, Administrator
(318) 495-3131 Ext: 109
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
7/13/2018
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