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VITAL RX LLC
DSH190133 ALLEN PARISH HOSPITAL
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Covered Entity Details
Entity Name
ALLEN PARISH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190133
Entity Address
108 6th Ave
KINDER, LA 70648
Medicare Provider Number
190133
Participating Start Date
10/1/2017
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
VITAL RX LLC
Pharmacy Address
237 CAHABA VALLEY PARKWAY
PELHAM, AL 35124
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/20/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jacqueline Reviel, Allen Parish Hospital CEO
(337) 738-9479
Contract Pharmacy Representative
VitalRx-Pelham
Michelle Maly, Pharmacy Manager
(205) 327-1084
Signed By Date
10/11/2018
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