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WALGREEN LOUISIANA CO., INC.
DSH190064 OUR LADY OF THE LAKE
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Covered Entity Details
Entity Name
OUR LADY OF THE LAKE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190064
Entity Address
REGIONAL MED CTR
5000 HENNESSY BLVD
BATON ROUGE, LA 70808-4375
Medicare Provider Number
190064
Participating Start Date
4/1/2008
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREEN LOUISIANA CO., INC.
Pharmacy Address
DBA: WALGREENS # 03047
5112 ESSEN LANE
BATON ROUGE, LA 70809
Pharmacy Comments
Contract Details
Approval Date
11/26/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/19/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Limbocker, CFO
(225) 765-8550
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/23/2012
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