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Walgreens MFC #21373
DSH190118 DESOTO REGIONAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
DESOTO REGIONAL HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190118
Entity Address
207 JEFFERSON STREET
MANSFIELD, LA 71052
Medicare Provider Number
190118
Participating Start Date
7/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
Walgreens MFC #21373
Pharmacy Address
4100 Dale Earnhardt Way
200
Northlake, TX 76262
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TODD EPPLER, CEO
(318) 871-3132
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2023
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