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CVS PHARMACY, INC.
DSH190013C WEST CALCASIEU-CAMERON HOSPITAL
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Covered Entity Details
Entity Name
WEST CALCASIEU-CAMERON HOSPITAL
Subdivision Name
Hackberry Rural Health Clinic - Hackberry Rural Health Clinic
Type
Disproportionate Share Hospital
340B ID
DSH190013C
Entity Address
1020 Main St,
Hackberry, LA 70645
Medicare Provider Number
190013
Outpatient Facility Provider Number
193997
Participating Start Date
10/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 02995
4101 TWIN CITY HWY
PORT ARTHUR, TX 77642
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
4/10/2024
Pharmacy closed
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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