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BROOKSHIRE PHARMACY #24
CAH191304-00 NORTH CADDO MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH CADDO MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191304-00
Entity Address
815 South Pine
VIVIAN, LA 71082
Medicare Provider Number
191304
Participating Start Date
7/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
BROOKSHIRE PHARMACY #24
Pharmacy Address
3000 N MARKET STREET
SHREVEPORT, LA 71107
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Jones Jones, CEO
(318) 375-4001
Contract Pharmacy Representative
Brookshire Grocery Company
Neil Ducote, Director of Pharmacy
(903) 600-1376
Signed By Date
1/9/2020
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