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WALGREEN LOUISIANA CO., INC.
DSH190102 OUR LADY OF LOURDES RMC
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Covered Entity Details
Entity Name
OUR LADY OF LOURDES RMC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190102
Entity Address
4801 AMBASSADOR CAFFERY PRKWY
LAFAYETTE, LA 70508
Medicare Provider Number
190102
Participating Start Date
1/1/2020
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN LOUISIANA CO., INC.
Pharmacy Address
DBA: WALGREENS # 04626
2517 KALISTE SALOOM ROAD
LAFAYETTE, LA 70508
Pharmacy Comments
Contract Details
Approval Date
7/18/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/9/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Crystal R Kiser, Manager
(337) 470-2131
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/18/2022
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