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WAL-MART PHARMACY 10-5997
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 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
1/26/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Anderson, Chief Financial Officer
(225) 658-4302
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/26/2017
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