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ONCOMED THE ONCOLOGY PHARMACY OF PHILADE
DSH190111C WILLIS KNIGHTON MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
W.K. CANCER CENTER
Type
Disproportionate Share Hospital
340B ID
DSH190111C
Entity Address
2600 KINGS HIGHWAY
SHREVEPORT, LA 71103
Medicare Provider Number
190111
Outpatient Facility Provider Number
Participating Start Date
1/1/2007
Last Recertification Date
8/17/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
ONCOMED THE ONCOLOGY PHARMACY OF PHILADE
Pharmacy Address
LLC DBA ONCO360
1553 CHESTER PIKE SUITE 206
CRUM LYNNE, PA 19022
Pharmacy Comments
Contract Details
Approval Date
7/23/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ROBERT D. HUIE, EXECUTIVE VP & CFO
(318) 212-4448
Contract Pharmacy Representative
Burt Zweigenhaft, CEO
(646) 356-7709
Signed By Date
7/23/2013
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