Contract Pharmacy Details

WINN DIXIE MONTGOMERY, LLC.
CH062350 IBERIA COMPRHESIVE COM HEALTH CNTR, INC.

Covered Entity Details

Entity Name

IBERIA COMPRHESIVE COM HEALTH CNTR, INC.

Subdivision Name

IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER

Type

HRSA-Funded Health Center

340B ID

CH062350

Entity Address

806 Jefferson Ter
New Iberia, LA 70560-5727

Grant Number

H80CS00697

Participating Start Date

12/1/1992

Last Recertification Date

2/18/2025

Pharmacy Details

Pharmacy Name

WINN DIXIE MONTGOMERY, LLC.

Pharmacy Address

WINN DIXIE PHARMACY # 1549
924 REES ST
BREAUX BRIDGE, LA 70517

Pharmacy Comments

Contract Details

Approval Date

4/2/2014

Contract Begin Date

7/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/23/2018
Pharmacy closed

Contacts

Covered Entity Signing Official

RODERICK C. CAMPBELL, CEO
(337) 365-4945 Ext: 128

Contract Pharmacy Representative

Curtis Hartin, Director of Pharmacy Managed Care
(904) 370-7776

Signed By Date

4/2/2014

340B Drug Pricing Program Database