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WAL-MART PHARMACY 10-0839
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 10-0839
Pharmacy Address
9350 CORTANA PL
BATON ROUGE, LA 70815
Pharmacy Comments
Contract Details
Approval Date
7/23/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/15/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Anderson, Chief Financial Officer
(225) 658-4302
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
7/23/2015
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