Contract Pharmacy Details

LOUISIANA CVS PHARMACY, L.L.C.
DSH190064 OUR LADY OF THE LAKE

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

LOUISIANA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY #06124
7411 FLORIDA BLVD.
BATON ROUGE, LA 70806

Pharmacy Comments

Contract Details

Approval Date

1/14/2015

Contract Begin Date

4/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/29/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jeffrey Limbocker, CFO
(225) 765-8550

Contract Pharmacy Representative

CVS Caremark
JACKLYN PARFITT, MANAGER, PAYER RELATIONS
(401) 770-6467

Signed By Date

1/14/2015

340B Drug Pricing Program Database