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LOUISIANA CVS PHARMACY, L.L.C.
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
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05327
9194 MANSFIELD RD
SHREVEPORT, LA 71118
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Jones Jones, CEO
(318) 375-4001
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/10/2020
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