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BROOKSHIRE PHARMACY
DSH190118 DESOTO REGIONAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
DESOTO REGIONAL HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190118
Entity Address
207 JEFFERSON STREET
MANSFIELD, LA 71052
Medicare Provider Number
190118
Participating Start Date
7/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
BROOKSHIRE PHARMACY
Pharmacy Address
1117 POLK STREET
MANSFIELD, LA 71052
Pharmacy Comments
Contract Details
Approval Date
4/4/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SANDRA ANDERSON, CFO
(318) 872-4610 Ext: 3102
Contract Pharmacy Representative
Brookshires
W Mark Sullivan, Pharmacy Operations
(903) 877-6852
Signed By Date
4/4/2019
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