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FRANCISCAN MISSIONARIES OF OUR LADY HEAL
DSH190102 OUR LADY OF LOURDES RMC
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Covered Entity Details
Entity Name
OUR LADY OF LOURDES RMC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190102
Entity Address
4801 AMBASSADOR CAFFERY PRKWY
LAFAYETTE, LA 70508
Medicare Provider Number
190102
Participating Start Date
1/1/2020
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
FRANCISCAN MISSIONARIES OF OUR LADY HEAL
Pharmacy Address
DBA RXONE TOWER DRIVE
2600 TOWER DR
STE 102
MONROE, LA 71201
Pharmacy Comments
Contract Details
Approval Date
1/5/2021
Contract Begin Date
4/1/2021
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
1/5/2021
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