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WAL-MART PHARMACY 10-0310
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 10-0310
Pharmacy Address
729 ODDFELLOWS ROAD
CROWLEY, LA 70526
Pharmacy Comments
Contract Details
Approval Date
10/11/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/24/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHARLES WHITSON, CFO
(337) 494-3204
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/11/2013
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