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WAL-MART PHARMACY 10-415
STD70359 Cardiovascular Institute of the South
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Covered Entity Details
Entity Name
Cardiovascular Institute of the South
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD70359
Entity Address
191 Innovation Ct
Suite A
Gray, LA 70359
Grant Number
NH25PS005176
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-415
Pharmacy Address
123 SAINT NAZAIRE RD
BROUSSARD, LA 70518
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
Ryan Hebert, CEO
(985) 873-5670
Contract Pharmacy Representative
Walmart
Nick Tallman, Sr. Director, Merchandise Operations – Pharmacy
(479) 371-0417
Signed By Date
4/14/2025
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