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VITAL CARE OF MISS-LOU, INC
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
VITAL CARE OF MISS-LOU, INC
Pharmacy Address
D/B/A LAKESIDE PHARMACY & GIFT
6280 HIGHWAY 129
PO BOX 37
MONTEREY, LA 71354
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
Vital Care of Miss-Lou, Inc dba Lakeside Pharmacy & Gift
Charles Edward Maier, Owner
(318) 386-2344
Signed By Date
10/8/2019
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