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ALBERTSONS LLC
DSH190002 LAFAYETTE GENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LAFAYETTE GENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190002
Entity Address
1214 COOLIDGE STREET
LAFAYETTE, LA 70503
Medicare Provider Number
190002
Participating Start Date
10/25/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
ALBERTSONS LLC
Pharmacy Address
ALBERTSONS PHARMACY #719
4400 AMBASSADOR CAFFERY PKWY
LAFAYETTE, LA 70508
Pharmacy Comments
Contract Details
Approval Date
7/10/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
al jude patin, SVP, Chief Operating Officer
(337) 289-7743
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/10/2020
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