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WAL-MART PHARMACY 10-0428
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
WAL-MART PHARMACY 10-0428
Pharmacy Address
5801 MAIN STREET
ZACHARY, LA 70791
Pharmacy Comments
Contract Details
Approval Date
2/27/2012
Contract Begin Date
2/27/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RANDALL M. OLSON, CEO
(225) 658-4303
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
2/24/2012
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