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Walgreens #21373
CAH191302-00 ST. MARTIN HOSPITAL
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Covered Entity Details
Entity Name
ST. MARTIN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191302-00
Entity Address
210 CHAMPAGNE BLVD.
BREAUX BRIDGE, LA 70517
Medicare Provider Number
191302
Participating Start Date
9/28/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
Walgreens #21373
Pharmacy Address
Walgreens Central Fill #21373
4100 Dale Earnhardt Way
STE 200
Northlake, TX 76262
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Glenn Dailey, CEO
(337) 261-6005
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2023
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