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SCPG LOUISIANA LLC
STD712541 Lake Providence Medical Clinic
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Covered Entity Details
Entity Name
Lake Providence Medical Clinic
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD712541
Entity Address
319 N. Hood Street
Lake Providence, LA 71254
Grant Number
NH25PS005176
Participating Start Date
10/1/2024
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
SCPG LOUISIANA LLC
Pharmacy Address
DBA: EXPRESS RX OF LAKE PROVIDENCE
302 LAKE STREET
LAKE PROVIDENCE, LA 71254
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
11/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amanda D Grey, COO
(318) 428-3237
Contract Pharmacy Representative
ExpressRX
Amanda Thornton, Pharmacist
(318) 559-2433
Signed By Date
10/15/2024
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