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BROOKSHIRE PHARMACY #38
CAH191301-00 UNION GENERAL HOSPITAL
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Covered Entity Details
Entity Name
UNION GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191301-00
Entity Address
901 JAMES AVE
FARMERVILLE, LA 71241
Medicare Provider Number
191301
Participating Start Date
4/1/2014
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
BROOKSHIRE PHARMACY #38
Pharmacy Address
1018 STERLINGTON HWY
FARMERVILLE, LA 71241
Pharmacy Comments
Contract Details
Approval Date
7/8/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
EVALYN ORMOND, CEO
(318) 368-7090
Contract Pharmacy Representative
Brookshires Pharmacy
Mark Sullivan, Central Fill Pharmacy Operations Manager
(903) 877-6852
Signed By Date
7/8/2019
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