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WAL-MART PHARMACY 10-0533
DSH190054 IBERIA MEDICAL CENTER
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Covered Entity Details
Entity Name
IBERIA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190054
Entity Address
2315 EAST MAIN STREET
NEW IBERIA, LA 70560
Medicare Provider Number
190054
Participating Start Date
7/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0533
Pharmacy Address
1205 E ADMIRAL DOYLE
NEW IBERIA, LA 70560
Pharmacy Comments
Contract Details
Approval Date
7/2/2012
Contract Begin Date
7/9/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Tucker, CEO
(337) 374-7104
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
7/4/2012
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