Contract Pharmacy Details

VITAL RX OF LOUISIANA
DSH190050 BEAUREGARD MEMORIAL HOSPITAL INC.

Covered Entity Details

Entity Name

BEAUREGARD MEMORIAL HOSPITAL INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH190050

Entity Address

600 S. PINE STREET
DERIDDER, LA 70634

Medicare Provider Number

190050

Participating Start Date

10/1/2015

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

VITAL RX OF LOUISIANA

Pharmacy Address

6200 LESLIE LN
LAKE CHARLES, LA 70615

Pharmacy Comments

Contract Details

Approval Date

7/13/2022

Contract Begin Date

10/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/22/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jarred Veillon, Chief Financial Officer
(337) 462-7495

Contract Pharmacy Representative

VitalRx
Bobby Wamble, COO
(256) 260-3350

Signed By Date

7/13/2022

340B Drug Pricing Program Database