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BAYOU PHARMACY LLC DBA BAYOU PHARMACY
FQHCLA336 BAYOUCLINIC, INC.
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Covered Entity Details
Entity Name
BAYOUCLINIC, INC.
Subdivision Name
BayouClinic, Inc.
Type
Health Center Program Look-Alike
340B ID
FQHCLA336
Entity Address
13833 Tapia Lane
Bayou La Batre, AL 36509-2515
Grant Number
LALCS00109
Participating Start Date
1/1/2016
Last Recertification Date
2/9/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
BAYOU PHARMACY LLC DBA BAYOU PHARMACY
Pharmacy Address
12855 PADGETT SWITCH RD
IRVINGTON, AL 36544-4015
Pharmacy Comments
Contract Details
Approval Date
4/25/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Julie Taylor, Executive Director
(251) 824-4985
Contract Pharmacy Representative
Semmes Pharmacy
Charles Cottrell, Owner
(251) 824-7979
Signed By Date
4/25/2017
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