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WAL-MART PHARMACY 10-0310
DSH190044 ACADIA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ACADIA GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190044
Entity Address
1305 CROWLEY RAYNE HWY.
CROWLEY, LA 70526
Medicare Provider Number
190044
Participating Start Date
4/1/2011
Last Recertification Date
8/27/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0310
Pharmacy Address
729 ODDFELLOWS ROAD
CROWLEY, LA 70526
Pharmacy Comments
Contract Details
Approval Date
1/14/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/9/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHARMAINE R. VIDRINE, CFO
(337) 788-6402
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/14/2015
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