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WAL-MART PHARMACY 10-0402
DSH190017 OPELOUSAS GENERAL HOSPITAL
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Covered Entity Details
Entity Name
OPELOUSAS GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190017
Entity Address
539 EAST PRUDHOMME ST
OPELOUSAS, LA 70570
Medicare Provider Number
190017
Participating Start Date
4/1/2003
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0402
Pharmacy Address
1932 REES STREET
BREAUX BRIDGE, LA 70517
Pharmacy Comments
Contract Details
Approval Date
4/6/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim Juneau, CFO
(337) 948-5133
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/6/2017
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