Contract Pharmacy Details

MEDICAL PHARMACY
DSH190020 LANE REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

LANE REGIONAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH190020

Entity Address

6300 MAIN STREET
ZACHARY, LA 70791

Medicare Provider Number

190020

Participating Start Date

4/1/2008

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

MEDICAL PHARMACY

Pharmacy Address

6400 MAIN ST.
PO BOX 475
ZACHARY, LA 70791

Pharmacy Comments

Contract Details

Approval Date

11/23/2010

Contract Begin Date

11/23/2010

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/2/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

RANDALL M. OLSON, CEO
(225) 658-4303

Contract Pharmacy Representative

JOHN LETARD, PRESIDENT
(225) 654-8383

Signed By Date

11/8/2010