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WALGREEN CO.
DSH190013B WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
W CALCASIEU CAMERON HOSP VINTON MED - Vinton Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH190013B
Entity Address
1611 HAMPTON STREET
VINTON, LA 70668-3707
Medicare Provider Number
190013
Outpatient Facility Provider Number
193458
Participating Start Date
10/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 03081
1408 N 16TH ST
ORANGE, TX 77630
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
4/14/2019
Business decision by covered entity and/or pharmacy
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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