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FRED'S PHARMACY # 2124
DSH190133 ALLEN PARISH HOSPITAL
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Covered Entity Details
Entity Name
ALLEN PARISH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190133
Entity Address
108 6th Ave
KINDER, LA 70648
Medicare Provider Number
190133
Participating Start Date
10/1/2017
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
FRED'S PHARMACY # 2124
Pharmacy Address
715 1ST AVE
KINDER, LA 70648-3511
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
10/15/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/29/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Jacqueline Reviel, Allen Parish Hospital CEO
(337) 738-9479
Contract Pharmacy Representative
Fred's Pharmacy
Nicole Pearson, 340B Program Manager
(901) 500-6153
Signed By Date
10/15/2019
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