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SUPER 1 PHARMACY #638
DSH190034 ABBEVILLE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ABBEVILLE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190034
Entity Address
118 NORTH HOSPITAL DRIVE
ABBEVILLE, LA 70510
Medicare Provider Number
190034
Participating Start Date
9/15/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SUPER 1 PHARMACY #638
Pharmacy Address
2210 VETERANS MEMORIAL DR.
ABBEVILLE, LA 70510
Pharmacy Comments
Contract Details
Approval Date
4/22/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
RAY LANDRY, CEO
(337) 898-6500
Contract Pharmacy Representative
Brookshire Grocery Company
Neil Ducote, Director of Pharmacy
(903) 600-1376
Signed By Date
4/22/2019
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