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FRANCISCAN MISSIONARIES OF OUR LADY HEAL
DSH190102E OUR LADY OF LOURDES RMC
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Covered Entity Details
Entity Name
OUR LADY OF LOURDES RMC
Subdivision Name
WCH AUDIOLOGY - WCH AUDIOLOGY
Type
Disproportionate Share Hospital
340B ID
DSH190102E
Entity Address
4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE, LA 70508
Medicare Provider Number
190102
Outpatient Facility Provider Number
Participating Start Date
4/1/2020
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
FRANCISCAN MISSIONARIES OF OUR LADY HEAL
Pharmacy Address
DBA RXONE LOURDES
4809 AMBASSADOR CAFFERY PKWY
STE 120A
LAFAYETTE, LA 70508
Pharmacy Comments
Contract Details
Approval Date
10/7/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Crystal R Kiser, Manager
(337) 470-2131
Contract Pharmacy Representative
FMOLHS
Adria Kerr, Corporate Director of Retail
(225) 765-9014
Signed By Date
10/7/2020
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