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LOUISIANA CVS PHARMACY, L.L.C.
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190111
Entity Address
2600 GREENWOOD ROAD
SHREVEPORT, LA 71103
Medicare Provider Number
190111
Participating Start Date
1/1/2007
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 4743
9510 ELLERBE RD.
SHREVEPORT, LA 71106
Pharmacy Comments
Contract Details
Approval Date
1/10/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Charles D. Daigle, COO
(318) 212-4292
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
1/10/2014
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