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SUPER 1 PHARMACY #604
SCH190007-00 NATCHITOCHES REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NATCHITOCHES REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH190007-00
Entity Address
501 KEYSER AVE
NATCHITOCHES, LA 71457
Medicare Provider Number
190007
Participating Start Date
9/7/2010
Last Recertification Date
9/13/2022
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
SUPER 1 PHARMACY #604
Pharmacy Address
5696 HIGHWAY 1 BYPASS
NATCHITOCHES, LA 71457
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Damian K. Soileau, CEO
(318) 214-4512
Contract Pharmacy Representative
Brookshire Grocery
John Stogner, CFO
(903) 893-0677
Signed By Date
7/12/2019
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