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WINN DIXIE MONTGOMERY, LLC.
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
WINN DIXIE MONTGOMERY, LLC.
Pharmacy Address
WINN DIXIE PHARMACY # 1581
5005 CHURCH ST
ZACHARY, LA 70791
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/21/2016
Pharmacy closed
Contacts
Covered Entity Signing Official
Mark Anderson, Chief Financial Officer
(225) 658-4302
Contract Pharmacy Representative
Curtis Hartin, Director of Pharmacy Managed Care
(904) 370-7776
Signed By Date
1/8/2014
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