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WAL-MART PHARMACY 10-5315
DSH190054 IBERIA MEDICAL CENTER
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Covered Entity Details
Entity Name
IBERIA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190054
Entity Address
2315 EAST MAIN STREET
NEW IBERIA, LA 70560
Medicare Provider Number
190054
Participating Start Date
7/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/6/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dionne E Viator, CFO
(337) 374-7107
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/6/2017
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