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MEDICAL PLAZA PHARMACY
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
MEDICAL PLAZA PHARMACY
Pharmacy Address
7777 HENNESSY BLVD
SUITE 114
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
4/12/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/16/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Limbocker, CFO
(225) 765-8550
Contract Pharmacy Representative
Lance Bourgoyne, Retail Pharmacy Manager
(225) 765-8140
Signed By Date
4/12/2013
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