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LOUISIANA CVS PHARMACY, L.L.C.
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
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05299
185 N. LEWIS ST..
NEW IBERIA, LA 70563
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/9/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stephanie Kirk, CFO
(337) 374-7107
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
7/7/2014
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