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WALMART PHARMACY 10-6932
CAH191304-00 NORTH CADDO MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH CADDO MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191304-00
Entity Address
815 South Pine
VIVIAN, LA 71082
Medicare Provider Number
191304
Participating Start Date
7/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-6932
Pharmacy Address
4701 NORTHPORT BLVD
SHREVEPORT, LA 71107
Pharmacy Comments
Contract Details
Approval Date
4/3/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Jones Jones, CEO
(318) 375-4001
Contract Pharmacy Representative
North Caddo Hospital Service District
Dakota Robinson, Controller
(318) 375-4097
Signed By Date
4/3/2019
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