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MEDICAL PLAZA PHARMACY
DSH190060 Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190060
Entity Address
1701 OAK PARK BOULEVARD
LAKE CHARLES, LA 70601
Medicare Provider Number
190060
Participating Start Date
1/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
MEDICAL PLAZA PHARMACY
Pharmacy Address
1717 OAK PARK BLVD STE 110
LAKE CHARLES, LA 70601-8977
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES WHITSON, CFO
(337) 494-3204
Contract Pharmacy Representative
Lake Charles Pharmaceutical Supply Company, LLC d/b/a Medical Plaza Pharmacy
Manley Jordan, Chief Medical Officer
(337) 494-2084
Signed By Date
1/11/2019
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