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ISLAND PHARMACY
DSH190145 LASALLE GENERAL HOSPITAL INC.
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Covered Entity Details
Entity Name
LASALLE GENERAL HOSPITAL INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190145
Entity Address
187 Ninth Street
JENA, LA 71342
Medicare Provider Number
190145
Participating Start Date
7/1/2019
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
ISLAND PHARMACY
Pharmacy Address
PO BOX 38
311 CHISUM ST.
SICILY ISLAND, LA 71368
Pharmacy Comments
Contract Details
Approval Date
10/8/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lana Francis, Chief Executive Officer
(318) 992-9154
Contract Pharmacy Representative
Island Pharmacy
Chuck Maier, Pharmacist Owner
(318) 389-5807
Signed By Date
10/8/2019
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