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WAL-MART PHARMACY 10-0533
DSH190002 LAFAYETTE GENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LAFAYETTE GENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190002
Entity Address
1214 COOLIDGE STREET
LAFAYETTE, LA 70503
Medicare Provider Number
190002
Participating Start Date
10/25/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0533
Pharmacy Address
1205 E ADMIRAL DOYLE
NEW IBERIA, LA 70560
Pharmacy Comments
Contract Details
Approval Date
1/18/2012
Contract Begin Date
1/18/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PATRICK GANDY, CEO
(337) 289-7475
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/11/2012
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