Contract Pharmacy Details

CVS PHARMACY, INC.
DSH190013A WEST CALCASIEU-CAMERON HOSPITAL

Covered Entity Details

Entity Name

WEST CALCASIEU-CAMERON HOSPITAL

Subdivision Name

ENT ASSOC W CALCASIEU CAMERON HOSPI - ENT Associates of West Calcasieu Cameron Hospital

Type

Disproportionate Share Hospital

340B ID

DSH190013A

Entity Address

1629 Beglis Parkway
SULPHUR, LA 70663-5641

Medicare Provider Number

190013

Outpatient Facility Provider Number

Participating Start Date

10/1/2018

Last Recertification Date

9/4/2020

Entity Termination Date

10/1/2021

Pharmacy Details

Pharmacy Name

CVS PHARMACY, INC.

Pharmacy Address

DBA: CVS/PHARMACY # 00851
485 TEXAS AVE
BRIDGE CITY, TX 77611

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

10/1/2021
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Jobie James, Chief Financial Officer
(337) 527-4143

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/15/2020

340B Drug Pricing Program Database