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SUPER ONE PHARMACY #603
DSH190116 MOREHOUSE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MOREHOUSE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190116
Entity Address
323 WEST WALNUT
BASTROP, LA 71220
Medicare Provider Number
190116
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SUPER ONE PHARMACY #603
Pharmacy Address
2211 E. MADISON AVE.
BASTROP, LA 71220
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2022
Agreement registered in error
Contacts
Covered Entity Signing Official
Derrick Frazier, Chief Executive Officer
(318) 283-3601
Contract Pharmacy Representative
Brookshires
W Mark Sullivan, Pharmacy Operations
(903) 877-6852
Signed By Date
4/18/2022
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