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DIPLOMAT SPECIALTY PHARMACY
DSH190020 LANE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LANE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190020
Entity Address
6300 MAIN STREET
ZACHARY, LA 70791
Medicare Provider Number
190020
Participating Start Date
4/1/2008
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683
Pharmacy Comments
04/09/2012 update address and name (added suite)
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alexsander Tewelde Peacock, Director of Pharmacy
(318) 381-5222
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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