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Walgreens #21373
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
Walgreens #21373
Pharmacy Address
Walgreens Central Fill #21373
4100 Dale Earnhardt Way
STE 200
Northlake, TX 76262
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
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
Lowell Edward Stanton, Chief Financial Officer
(337) 470-2147
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2023
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