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LOUISIANA CVS PHARMACY, L.L.C.
DSH190013A WEST CALCASIEU-CAMERON HOSPITAL
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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
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16738
1720 W PRIEN LAKE RD
LAKE CHARLES, LA 70601
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
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