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VITAL RX OF LOUISIANA
DSH190017 OPELOUSAS GENERAL HOSPITAL
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Covered Entity Details
Entity Name
OPELOUSAS GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190017
Entity Address
539 EAST PRUDHOMME ST
OPELOUSAS, LA 70570
Medicare Provider Number
190017
Participating Start Date
4/1/2003
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
VITAL RX OF LOUISIANA
Pharmacy Address
6200 LESLIE LN
LAKE CHARLES, LA 70615
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jim Juneau, CFO
(337) 948-5133
Contract Pharmacy Representative
VitalRx
Bobby Wamble, COO
(256) 260-3350
Signed By Date
4/16/2018
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