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WALGREEN LOUISIANA CO., INC.
DSH190039C WEST JEFFERSON MEDICAL CENTER
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Covered Entity Details
Entity Name
WEST JEFFERSON MEDICAL CENTER
Subdivision Name
MANHATTAN FAMILY DOCTORS
Type
Disproportionate Share Hospital
340B ID
DSH190039C
Entity Address
2845 MANHATTAN BLVD.
HARVEY, LA 70058
Medicare Provider Number
190039
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
Entity Termination Date
10/1/2017
Pharmacy Details
Pharmacy Name
WALGREEN LOUISIANA CO., INC.
Pharmacy Address
DBA: WALGREENS #15200
2001 CAROL SUE AVE
GRETNA, LA 70056-4445
Pharmacy Comments
Contract Details
Approval Date
6/15/2010
Contract Begin Date
6/15/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
5/28/2010
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