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WAL-MART PHARMACY 10-0469
DSH190060 Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190060
Entity Address
1701 OAK PARK BOULEVARD
LAKE CHARLES, LA 70601
Medicare Provider Number
190060
Participating Start Date
1/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0469
Pharmacy Address
3415 US 14
LAKE CHARLES, LA 70607
Pharmacy Comments
Contract Details
Approval Date
4/6/2012
Contract Begin Date
4/6/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES WHITSON, CFO
(337) 494-3204
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
3/23/2012
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