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WALMART PHARMACY 10-5169
DSH190060 Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190060
Entity Address
1701 OAK PARK BOULEVARD
LAKE CHARLES, LA 70601
Medicare Provider Number
190060
Participating Start Date
1/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Devon Hyde, President/CEO
(337) 494-3200
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
1/17/2023
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