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MEDICAL PHARMACY WEST
DSH190020 LANE REGIONAL MEDICAL CENTER
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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 WEST
Pharmacy Address
2250 CHURCH STREET
PO BOX 475
ZACHARY, LA 70791
Pharmacy Comments
Contract Details
Approval Date
11/30/2010
Contract Begin Date
11/30/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/2/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/8/2010
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