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WINN DIXIE PHARMACY #1561
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
WINN DIXIE PHARMACY #1561
Pharmacy Address
2240 AMBASSADOR CAFFERY PKWY
LAFAYETTE, LA 70506
Pharmacy Comments
Contract Details
Approval Date
3/7/2012
Contract Begin Date
3/8/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/8/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Patrick Gandy, CEO
(337) 289-7888
Contract Pharmacy Representative
Peter Lynch, President, CEO
(904) 783-5855
Signed By Date
3/2/2012
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