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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
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
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Jim Juneau, CFO
(337) 948-5133
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/11/2017
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