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SUPER 1 PHARMACY #648
CH0610680 INNIS COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
INNIS COMMUNITY HEALTH CENTER, INC.
Subdivision Name
INNIS COMMUNITY HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH0610680
Entity Address
6450 LA HIGHWAY 1 STE B
INNIS, LA 70747-0889
Grant Number
H80CS00855
Participating Start Date
1/1/2004
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
SUPER 1 PHARMACY #648
Pharmacy Address
213 HOSPITAL RD
NEW ROADS, LA 70760
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
cindy peavy, Executive Director
(225) 235-9627
Contract Pharmacy Representative
Brookshires
W Mark Sullivan, Pharmacy Operations
(903) 877-6852
Signed By Date
1/15/2020
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