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WAL-MART PHARMACY 10-0448
DSH190098 University Health Shreveport, LLC
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Covered Entity Details
Entity Name
University Health Shreveport, LLC
Subdivision Name
UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH190098
Entity Address
1541 KINGS HIGHWAY
SHREVEPORT, LA 71103
Medicare Provider Number
190098
Participating Start Date
1/1/1998
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0448
Pharmacy Address
6235 WESTPORT AVENUE
SHREVEPORT, LA 71129
Pharmacy Comments
Contract Details
Approval Date
10/31/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Randolph, President
(318) 626-0982
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/31/2016
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