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IC PHARMACY LLC
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
IC PHARMACY LLC
Pharmacy Address
AMAZON PHARMACY #004
34 35TH STREET
STE 4BSW, UNIT 28
BROOKLYN, NY 11232
Pharmacy Comments
Contract Details
Approval Date
10/9/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TODD EPPLER, CEO
(318) 871-3132
Contract Pharmacy Representative
AMAZON PHARMACY
JOHN M LAVIN, MANAGING OFFICER
(602) 793-8552
Signed By Date
10/9/2024
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