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RXONE LAKE
DSH190064 OUR LADY OF THE LAKE
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Covered Entity Details
Entity Name
OUR LADY OF THE LAKE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190064
Entity Address
REGIONAL MED CTR
5000 HENNESSY BLVD
BATON ROUGE, LA 70808-4375
Medicare Provider Number
190064
Participating Start Date
4/1/2008
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
RXONE LAKE
Pharmacy Address
5000 HENNESSY BLVD
CHAPEL HALLWAY RM 101
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeffrey Limbocker, CFO
(225) 765-8550
Contract Pharmacy Representative
FMOLHS
Adria Kerr, Corporate Director of Retail
(225) 765-9014
Signed By Date
1/12/2018
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