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WALGREEN LOUISIANA CO., INC.
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
WALGREEN LOUISIANA CO., INC.
Pharmacy Address
DBA: WALGREENS #13134
6130 JOHNSTON ST.
LAFAYETTE, LA 70503
Pharmacy Comments
Contract Details
Approval Date
10/1/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PATRICK GANDY, CEO
(337) 289-7475
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/1/2013
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