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WINN DIXIE MONTGOMERY, LLC.
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
WINN DIXIE MONTGOMERY, LLC.
Pharmacy Address
WINN DIXIE PHARMACY # 1444
12125 HWY 90
LULING, LA 70070
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Alexsander Tewelde Peacock, Director of Pharmacy
(318) 381-5222
Contract Pharmacy Representative
Lane Regional Medical Center
Alexsander Tewelde Peacock, Director of Pharmacy
(318) 381-5222
Signed By Date
7/15/2021
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