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LOUISIANA CVS PHARMACY, L.L.C.
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
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05455
1269 SAM HOUSTON JONES PKWY
LAKE CHARLES, LA 70611
Pharmacy Comments
Contract Details
Approval Date
10/11/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES WHITSON, CFO
(337) 494-3204
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
10/11/2013
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