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CYSTIC FIBROSIS SERVICES, LLC
DSH190013A WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
ENT ASSOC W CALCASIEU CAMERON HOSPI - ENT Associates of West Calcasieu Cameron Hospital
Type
Disproportionate Share Hospital
340B ID
DSH190013A
Entity Address
1629 Beglis Parkway
SULPHUR, LA 70663-5641
Medicare Provider Number
190013
Outpatient Facility Provider Number
Participating Start Date
10/1/2018
Last Recertification Date
9/4/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jobie James, Chief Financial Officer
(337) 527-4143
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2018
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