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SUPER 1 PHARMACY #604
DSH190007 NATCHITOCHES REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NATCHITOCHES REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190007
Entity Address
501 KEYSER AVENUE
NATCHITOCHES, LA 71457
Medicare Provider Number
190007
Participating Start Date
10/1/2022
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SUPER 1 PHARMACY #604
Pharmacy Address
5696 HIGHWAY 1 BYPASS
NATCHITOCHES, LA 71457
Pharmacy Comments
Contract Details
Approval Date
9/14/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Damian K. Soileau, CEO
(318) 214-4512
Contract Pharmacy Representative
Brookshire Grocery
John Stogner, CFO
(903) 893-0677
Signed By Date
7/14/2022
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