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WAL-MART PHARMACY 10-0876
SCH190007-00 NATCHITOCHES REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NATCHITOCHES REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH190007-00
Entity Address
501 KEYSER AVE
NATCHITOCHES, LA 71457
Medicare Provider Number
190007
Participating Start Date
9/7/2010
Last Recertification Date
9/13/2022
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0876
Pharmacy Address
25800 HWY 171
MANY, LA 71449
Pharmacy Comments
7/25/12-changed from Highway 17
Contract Details
Approval Date
4/10/2012
Contract Begin Date
4/10/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/10/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MARK MARLEY, CEO
(318) 214-4512
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
3/30/2012
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