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WAL-MART PHARMACY 10-1106
CAH191318-00 Concordia Parish Hospital Service District 1 DBA Trinity Medical
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Covered Entity Details
Entity Name
Concordia Parish Hospital Service District 1 DBA Trinity Medical
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191318-00
Entity Address
6569 Hwy 84
Ferriday, LA 71334
Medicare Provider Number
191318
Participating Start Date
10/1/2011
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1106
Pharmacy Address
4283 CARTER STREET
VIDALIA, LA 71373
Pharmacy Comments
Contract Details
Approval Date
1/13/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/16/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William Rucker, Administrator
(318) 757-6551 Ext: 353
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/13/2015
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