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WALGREEN LOUISIANA CO., INC.
DSH190039F WEST JEFFERSON MEDICAL CENTER
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Covered Entity Details
Entity Name
WEST JEFFERSON MEDICAL CENTER
Subdivision Name
INTERNAL MEDICINE
Type
Disproportionate Share Hospital
340B ID
DSH190039F
Entity Address
1111 MEDICAL CENTER BLVD.
SUITE S850
MARRERO, LA 70072
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 # 05633
2570 BARATARIA BLVD
MARRERO, LA 70072
Pharmacy Comments
Contract Details
Approval Date
4/5/2010
Contract Begin Date
4/5/2010
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
3/18/2010
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