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WAL-MART PHARMACY 10-0876
DSH190041 CHRISTUS Shreveport-Bossier Health System
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Covered Entity Details
Entity Name
CHRISTUS Shreveport-Bossier Health System
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190041
Entity Address
1453 E. Bert Kouns Industrial Loop
Shreveport, LA 71105
Medicare Provider Number
190041
Participating Start Date
7/1/2024
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0876
Pharmacy Address
25800 HWY 171
MANY, LA 71449
Pharmacy Comments
7/25/12-changed from Highway 17
Contract Details
Approval Date
4/10/2012
Contract Begin Date
4/10/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/26/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephen F. Wright, President and CEO
(318) 448-6701
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
3/30/2012
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