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WINN DIXIE MONTGOMERY, LLC.
DSH190045 ST. TAMMANY PARISH HOSPITAL
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Covered Entity Details
Entity Name
ST. TAMMANY PARISH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190045
Entity Address
St. Tammany Parish Hospital
1202 S. Tyler Street
COVINGTON, LA 70433
Medicare Provider Number
190045
Participating Start Date
10/1/2018
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WINN DIXIE MONTGOMERY, LLC.
Pharmacy Address
WINN DIXIE PHARMACY # 1500
4100 HWY 59
MANDEVILLE, LA 70471
Pharmacy Comments
Contract Details
Approval Date
7/16/2021
Contract Begin Date
7/26/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/12/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Sandra DiPietro, Senior Vice President/Chief Financial Officer
(985) 898-4583
Contract Pharmacy Representative
Southeastern Grocers LLC
Michael LeBlanc, Sr.Director, Pharmacy
(904) 783-5897
Signed By Date
7/16/2021
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