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BOUDREAUX'S SPECIALTY COMPOUNDING PHARMA
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.
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Covered Entity Details
Entity Name
WILLIS KNIGHTON MEDICAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190111
Entity Address
2600 GREENWOOD ROAD
SHREVEPORT, LA 71103
Medicare Provider Number
190111
Participating Start Date
1/1/2007
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
BOUDREAUX'S SPECIALTY COMPOUNDING PHARMA
Pharmacy Address
2551 GREENWOOD RD STE 110
SHREVEPORT, LA 71103-3984
Pharmacy Comments
Contract Details
Approval Date
4/14/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384
Contract Pharmacy Representative
Boudreaux's Specialty Compounding Pharmacy
Jared A Ocmand, PIC
(318) 631-2005
Signed By Date
4/14/2025
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