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WALGREEN CO.
DSH190013C WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
Hackberry Rural Health Clinic - Hackberry Rural Health Clinic
Type
Disproportionate Share Hospital
340B ID
DSH190013C
Entity Address
1020 Main St,
Hackberry, LA 70645
Medicare Provider Number
190013
Outpatient Facility Provider Number
193997
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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