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DIPLOMAT SPECIALTY PHARMACY
DSH190064 OUR LADY OF THE LAKE
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Covered Entity Details
Entity Name
OUR LADY OF THE LAKE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190064
Entity Address
REGIONAL MED CTR
5000 HENNESSY BLVD
BATON ROUGE, LA 70808-4375
Medicare Provider Number
190064
Participating Start Date
4/1/2008
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683
Pharmacy Comments
04/09/2012 update address and name (added suite)
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/16/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Limbocker, CFO
(225) 765-8550 Ext: 2259077045
Contract Pharmacy Representative
Diplomat Pharmacy
Justin Ott, Market Development Manager
(810) 768-9102
Signed By Date
10/15/2018
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