Contract Pharmacy Details

WALGREEN LOUISIANA CO., INC.
DSH190039F WEST JEFFERSON MEDICAL CENTER

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 # 06637
1544 MANHATTAN BLVD
HARVEY, LA 70058

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

340B Drug Pricing Program Database