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WAL-MART PHARMACY 10-0448
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 10-0448
Pharmacy Address
6235 WESTPORT AVENUE
SHREVEPORT, LA 71129
Pharmacy Comments
Contract Details
Approval Date
1/25/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Contacts
Covered Entity Signing Official
Isaac Palmer, CEO
(318) 681-5729
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/25/2016
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