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PONCHATOULA FAMILY PHARMACY
DSH190015 North Oaks Medical Center LLC
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Covered Entity Details
Entity Name
North Oaks Medical Center LLC
Subdivision Name
DBA NORTH OAKS MEDICAL CENTER LLC
Type
Disproportionate Share Hospital
340B ID
DSH190015
Entity Address
15790 PAUL VEGA M.D. DRIVE
HAMMOND, LA 70403
Medicare Provider Number
190015
Participating Start Date
4/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
PONCHATOULA FAMILY PHARMACY
Pharmacy Address
19008 HIGHWAY 22
PONCHATOULA, LA 70454-6780
Pharmacy Comments
Contract Details
Approval Date
10/6/2021
Contract Begin Date
12/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark T Anderson, CFO
(985) 230-6602
Contract Pharmacy Representative
Albany Drugs
Lindsey Driscoll, Certified Pharmacy Technician
(225) 567-7772
Signed By Date
10/6/2021
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