Covered Entity Details

FQHCLA335AN LEE MEMORIAL HEALTH SYSTEM (Terminated) - information as of 4/24/2025 10:09:17 PM

Main Details

Name

LEE MEMORIAL HEALTH SYSTEM

Subdivision Name

Internal Medicine Office Matthew Drive

Type

Health Center Program Look-Alike

Site ID

BPS-LAL-036959

340B ID

FQHCLA335AN

Grant Number

LALCS00171

Additional Details

Current Program Status

Terminated

Registration Date

10/9/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/16/2023

Last Recertification Date

2/1/2024

Termination Date
Termination Reason

1/1/2025
Business decision by the Covered Entity

Contacts

Authorizing Official

Lee Health
Rachel Suzanne Walter, System Director, FQHC-LA
(239) 823-5840

Primary Contact

Lee Health
Joseph Bitner, Compliance Officer
(239) 343-8602

Addresses

Street Address

1569 Matthew Dr
Fort Myers, FL 33907-1701

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
FQHCLA335	Terminated	BPS-LAL-014712	LEE MEMORIAL HEALTH SYSTEM	North Fort Myers Medical Office	13279 N CLEVELAND AVE	NORTH FORT MYERS	FL
FQHCLA335A	Terminated	BPS-LAL-014713	LEE MEMORIAL HEALTH SYSTEM	P.L. Dunbar Medical Office	3511 Dr. Martin Luther King, Jr. Boulevard	Fort Myers	FL
FQHCLA335AA	Terminated	BPS-LAL-034511	Lee Memorial Health System	Adult Cardiology Office - Cape Coral	708 Del Prado Blvd S STE 7	Cape Coral	FL
FQHCLA335AB	Terminated	BPS-LAL-034240	Lee Memorial Health System	Adult Infectious Disease Office	2780 Cleveland Ave STE 809	Fort Myers	FL
FQHCLA335AC	Terminated	BPS-LAL-035117	Lee Memorial Health System	Adult Urology Office	12651 Whitehall Dr	Fort Myers	FL
FQHCLA335AD	Terminated	BPS-LAL-034510	Lee Memorial Health System	Adult Cardiology Office @ The Sanctuary	8960 Colonial Center Dr STE 304	Fort Myers	FL
FQHCLA335AE	Terminated	BPS-LAL-035248	Lee Memorial Health System	Adult Neurology Office	12600 Creekside Lane STE 2	Fort Myers	FL
FQHCLA335AF	Terminated	BPS-LAL-035330	Lee Memorial Health System	Golisano Pediatric Behavioral Health Office - Lehigh Acres	3415 Lee Blvd	Lehigh Acres	FL
FQHCLA335AG	Terminated	BPS-LAL-035649	Lee Memorial Health System	Golisano Pediatric Behavioral Health Office – Bonita Springs	3501 Health Center Blvd Ste 2190	Estero	FL
FQHCLA335AH	Terminated	BPS-LAL-036434	Lee Memorial Health System	Adult Gastroenterology Office @ MPO	9800 HealthPark Drive STE 110	Fort Myers	FL
FQHCLA335AJ	Terminated	BPS-LAL-036294	Lee Memorial Health System	Permanent Site - Dunbar Medical Office	3637 Dr Martin Luther King Jr Blvd	Fort Myers	FL
FQHCLA335AK	Terminated	BPS-LAL-036295	Lee Memorial Health System	Lee Physician Group OB/GYN	15901 Bass Road STE 100	Fort Myers	FL
FQHCLA335AL	Terminated	BPS-LAL-036433	LEE MEMORIAL HEALTH SYSTEM	Dunbar Medical Office	3637 Dr. Martin Luther King Jr. Blvd.	Fort Myers	FL
FQHCLA335AM	Terminated	BPS-LAL-036960	LEE MEMORIAL HEALTH SYSTEM	Family Practice Medical Office Clayton Ct	5225 Clayton Ct	Fort Myers	FL
FQHCLA335AN	Terminated	BPS-LAL-036959	LEE MEMORIAL HEALTH SYSTEM	Internal Medicine Office Matthew Drive	1569 Matthew Dr	Fort Myers	FL
FQHCLA335AP	Terminated	BPS-LAL-037093	LEE MEMORIAL HEALTH SYSTEM	The Sanctuary Family Medicine Office	8960 Colonial Center Dr, #300	Fort Myers	FL
FQHCLA335AQ	Terminated	BPS-LAL-037511	LEE MEMORIAL HEALTH SYSTEM	Labelle Internal Medicine Office	930 S Main St	Labelle	FL
FQHCLA335AR	Terminated	BPS-LAL-037799	LEE MEMORIAL HEALTH SYSTEM	Golisano Pediatric ENT Office	16410 Healthpark Commons Dr	Fort Myers	FL
FQHCLA335B	Terminated	BPS-LAL-016848	LEE MEMORIAL HEALTH SYSTEM	Cape Coral Medical Office	1435 SE 8th Terrace	Cape Coral	FL
FQHCLA335C	Terminated	BPS-LAL-021185	LEE MEMORIAL HEALTH SYSTEM	Lehigh Acres Medical Office	5705 Lee Boulevard	Lehigh Acres	FL
FQHCLA335D	Terminated	BPS-LAL-021148	LEE MEMORIAL HEALTH SYSTEM	East Fort Myers Ob/Gyn Medical Office	4040 Palm Beach Boulevard, Suite F	Fort Myers	FL
FQHCLA335E	Terminated	BPS-LAL-021147	LEE MEMORIAL HEALTH SYSTEM	South Fort Myers Ob/Gyn Medical Office	9800 S. Healthpark Dr.	Fort Myers	FL
FQHCLA335F	Terminated	BPS-LAL-030599	Lee Memorial Health System	Golisano Pediatrics Port Charlotte Caring Way	2484 Caring Way Unit F	Port Charlotte	FL
FQHCLA335G	Terminated	BPS-LAL-029631	Lee Memorial Health System	Lehigh Acres East Pediatric Office	260 Beth Stacey Blvd	Lehigh Acres	FL
FQHCLA335H	Terminated	BPS-LAL-029912	Lee Memorial Health System	Cape Coral Pediatric Office	650 Del Prado Blvd S	Cape Coral	FL
FQHCLA335J	Terminated	BPS-LAL-029630	Lee Memorial Health System	Page Field Pediatric Office	4751 S Cleveland Ave	Fort Myers	FL
FQHCLA335K	Terminated	BPS-LAL-030506	Lee Memorial Health System	Bonita Springs Pediatric Office	23450 Via Coconut Pt	Estero	FL
FQHCLA335L	Terminated	BPS-LAL-030598	Lee Memorial Health System	Golisano Pediatrics Port Charlotte Harbor Blvd.	2525 Harbor Blvd Ste 204	Port Charlotte	FL
FQHCLA335M	Terminated	BPS-LAL-031245	Lee Memorial Health System	South Fort Myers Ob/Gyn Medical Office	9800 S Healthpark Dr Ste 205	Fort Myers	FL
FQHCLA335N	Terminated	BPS-LAL-031246	Lee Memorial Health System	New Brittany Behavioral Health Office	12550 New Brittany Blvd	Fort Myers	FL
FQHCLA335P	Terminated	BPS-LAL-031470	Lee Memorial Health System	Golisano Pediatric Behavioral and Neurological Health Office	15901 Bass Rd, Ste 108	Fort Myers	FL
FQHCLA335Q	Terminated	BPS-LAL-031982	Lee Memorial Health System	Golisano Pediatric ENT and Gastroenterology Office	16230 Summerlin Rd Ste 215	Fort Myers	FL
FQHCLA335R	Terminated	BPS-LAL-031983	Lee Memorial Health System	Golisano Pediatric Cardiology Specialty Office	16281 Bass Rd Ste 304	Fort Myers	FL
FQHCLA335S	Terminated	BPS-LAL-033390	Lee Memorial Health System	Golisano Pediatric Endocrinology and Nephrology Office	15901 Bass Rd Ste 102	Fort Myers	FL
FQHCLA335T	Terminated	BPS-LAL-033392	Lee Memorial Health System	Adult Endocrinology Office @ The Sanctuary	8960 Colonial Center Dr Ste 202	Fort Myers	FL
FQHCLA335U	Terminated	BPS-LAL-032599	Lee Memorial Health System	Adult Rheumatology Office @ The Sanctuary	8960 Colonial Center Dr Ste 302	Fort Myers	FL
FQHCLA335V	Terminated	BPS-LAL-034239	Lee Memorial Health System	SWFL Children’s Charities Eye Institute of Golisano Children’s Hospital	11390 Summerlin Square Dr	Fort Myers Beach	FL
FQHCLA335W	Terminated	BPS-LAL-031993	Lee Memorial Health System	Children's Eye Institute of Golisano Children's Hospital	9800 S Healthpark Dr Ste 110	Fort Myers	FL
FQHCLA335X	Terminated	BPS-LAL-039066	Lee Memorial Health System	Adult Hematology/Oncology Office	8931 Colonial Center Dr, #300	Fort Myers	FL
FQHCLA335Y	Terminated	BPS-LAL-034237	Lee Memorial Health System	Adult Pulmonology Office	5216 Clayton Ct	Fort Myers	FL
FQHCLA335Z	Terminated	BPS-LAL-034507	Lee Memorial Health System	Adult Gastroenterology Office	16410 Healthpark Commons Dr	Fort Myers	FL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
FQHCLA335	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/01/2022	01/01/2025
FQHCLA335	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/01/2022	01/01/2025
FQHCLA335	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/01/2022	01/01/2025
FQHCLA335	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	04/01/2022	07/31/2023
FQHCLA335	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/01/2022	01/01/2025
FQHCLA335	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/01/2022	01/01/2025
FQHCLA335	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2024	01/01/2025
FQHCLA335	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/01/2024	01/01/2025
FQHCLA335	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	07/01/2024	01/01/2025
FQHCLA335	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/01/2022	01/01/2025
FQHCLA335	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/01/2022	01/01/2025
FQHCLA335	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/01/2022	01/01/2025
FQHCLA335	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/01/2022	01/01/2025
FQHCLA335	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/01/2022	01/01/2025
FQHCLA335	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/01/2022	01/01/2025
FQHCLA335	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/01/2022	01/01/2025
FQHCLA335	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/01/2022	01/01/2025
FQHCLA335	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/01/2022	01/01/2025
FQHCLA335	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/01/2022	01/01/2025
FQHCLA335	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/01/2022	01/01/2025
FQHCLA335	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/01/2022	01/01/2025
FQHCLA335	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/01/2022	01/01/2025
FQHCLA335	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/01/2022	01/01/2025
FQHCLA335	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2024	01/01/2025
FQHCLA335	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/01/2022	01/01/2025
FQHCLA335	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/01/2022	01/01/2025
FQHCLA335	GENOA HEALTHCARE LLC	3763 EVANS AVE SUITE S140		FORT MYERS	FL	33901	07/01/2023	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 02982	13591 JETPORT COMMERCE PKWY.	FORT MYERS	FL	33913	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00406	2400 TAMIAMI TRL	PUNTA GORDA	FL	33950	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03281	11241 MIROMAR SQUARE BLVD	ESTERO	FL	33928	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03266	4890 TAMIAMI TR	NAPLES	FL	34112	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03107	24 S. BREVARD AVE.	ARCADIA	FL	34266	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05410	4478 TAMIAMI TRAIL	PORT CHARLOTTE	FL	33980	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16211	1400A TAMIAMI TRL	PORT CHARLOTTE	FL	33948	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03274	9852 STRINGFELLOW RD	SAINT JAMES CITY	FL	33956	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03296	4710 PALM BEACH BLVD	FORT MYERS	FL	33905	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03552	27841 CROWN LAKE BLVD. PO BOX 2327	BONITA SPRINGS	FL	34135	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00196	15550 SAN CARLOS BLVD.	FORT MYERS	FL	33908	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17151	2415 TARPON BAY BLVD	NAPLES	FL	34119	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05785	1209 DEL PRADO BLVD., SOUTH	CAPE CORAL	FL	33990	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04224	1003 SANTA BARBARA BLVD	CAPE CORAL	FL	33991	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01013	1760 S MCCALL RD	ENGLEWOOD	FL	34223	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03258	14998 S. TAMIAMI TRAIL	NORTH PORT	FL	34287	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17383	1890 NE PINE ISLAND ROAD	CAPE CORAL	FL	33909	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04726	24200 VETERANS BLVD	PORT CHARLOTTE	FL	33954	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05041	5585 GOLDEN GATE PKWY	NAPLES	FL	34116	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03277	5990 S POINTE BLVD	FORT MYERS	FL	33919	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05236	9170 DANIELS PKWY	FORT MYERS	FL	33912	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05787	11500 BONITA BEACH RD. SE	BONITA SPRINGS	FL	34135	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 04608	24800 S TAMIAMI TRL	BONITA SPRINGS	FL	34134	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03164	520 W SUGARLAND HWY	CLEWISTON	FL	33440	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 00453	15050 N CLEVELAND AVE	NORTH FORT MYERS	FL	33903	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03248	1102 N 15TH ST	IMMOKALEE	FL	34142	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07983	11300 STATE ROAD 82	FORT MYERS	FL	33905	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03122	2480 TAMIAMI TRL	PORT CHARLOTTE	FL	33952	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 09996	6391 BAYSHORE RD.	NORTH FORT MYERS	FL	33917	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07902	1611 PINE ISLAND RD NE	CAPE CORAL	FL	33909	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA CVS/PHARMACY #4738	13400 IMMOKALEE ROAD	NAPLES	FL	34120	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 07890	7581 WINKLER RD	FORT MYERS	FL	33908	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05116	16961 ALICO MISSION WAY	FORT MYERS	FL	33908	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01807	1350 LEE BLVD	LEHIGH ACRES	FL	33936	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03349	19070 S TAMIAMI TRAIL	FORT MYERS	FL	33908	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03622	4100 HANCOCK BRIDGE PKWY	NORTH FORT MYERS	FL	33903	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 08397	7380 DAVIS BLVD	NAPLES	FL	34104	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 01067	737 CAPE CORAL PKWY E	CAPE CORAL	FL	33904	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 17433	9350 DYNASTY DR	FT MYERS	FL	33905	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16265	13711 S TAMIAMI TRL	FORT MYERS	FL	33912	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03433	14411 PALM BEACH BLVD	FORT MYERS	FL	33905	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05187	2375 VANDERBILT BEACH RD	NAPLES	FL	34109	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 08927	8831 IMMOKALEE RD.	NAPLES	FL	34120	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	CVS PHARMACY # 16786	2430 SANTA BARBARA BLVD	CAPE CORAL	FL	33914	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05185	12255 S CLEVELAND AVE.	FORT MYERS	FL	33907	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03941	2403 CLEVELAND AVE	FORT MYERS	FL	33901	04/01/2022	01/01/2025
FQHCLA335	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 05824	2515 SHADOWLAWN DR.	NAPLES	FL	34112	04/01/2022	01/01/2025
FQHCLA335E	LEE MEMORIAL HEALTH SYSTEM	GOLISANO CHILDREN'S HOSPITAL OF SOUTHWES	9981 S HEALTHPARK DR CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA	FORT MYERS	FL	33908-3618	01/01/2018	10/10/2019
FQHCLA335C	LEE MEMORIAL HEALTH SYSTEM	GOLISANO CHILDREN'S HOSPITAL OF SOUTHWES	9981 S HEALTHPARK DR CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA	FORT MYERS	FL	33908-3618	01/01/2018	10/10/2019
FQHCLA335D	LEE MEMORIAL HEALTH SYSTEM	GOLISANO CHILDREN'S HOSPITAL OF SOUTHWES	9981 S HEALTHPARK DR CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA	FORT MYERS	FL	33908-3618	01/01/2018	10/10/2019
FQHCLA335A	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2018	08/01/2022
FQHCLA335A	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2018	08/01/2022
FQHCLA335B	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2018	08/01/2022
FQHCLA335B	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2018	08/01/2022
FQHCLA335E	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2018	10/01/2022
FQHCLA335C	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2018	08/01/2022
FQHCLA335C	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2018	08/01/2022
FQHCLA335D	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2018	08/01/2022
FQHCLA335A	LEE MEMORIAL HEALTH SYSTEM	GOLISANO CHILDREN'S HOSPITAL OF SOUTHWES	9981 S HEALTHPARK DR CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA	FORT MYERS	FL	33908-3618	01/01/2018	10/10/2019
FQHCLA335B	LEE MEMORIAL HEALTH SYSTEM	GOLISANO CHILDREN'S HOSPITAL OF SOUTHWES	9981 S HEALTHPARK DR CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA	FORT MYERS	FL	33908-3618	01/01/2018	10/10/2019
FQHCLA335D	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2018	08/01/2022
FQHCLA335E	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2018	10/01/2022
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 4	636 DEL PRADO BLVD S	CAPE CORAL	FL	33990-2668	01/01/2020	04/13/2022
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 3	13681 DOCTORS WAY	FORT MYERS	FL	33912	01/01/2020	04/13/2022
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 1	2776 CLEVELAND AVE	FORT MYERS	FL	33901-5864	01/01/2020	01/01/2025
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 5	4751 S CLEVELAND AVE	FORT MYERS	FL	33907-1317	01/01/2020	01/01/2025
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	LEE PHARMACY 7	23450 VIA COCONUT PT	ESTERO	FL	34135-1877	07/22/2020	01/01/2025
FQHCLA335	LEE MEMORIAL HEALTH SYSTEM	D/B/A LEE HEALTH HOME INFUSION	11220 METRO PKWY STE 31 D/B/A LEE HEALTH HOME INFUSION	FORT MYERS	FL	33966-1291	07/01/2023	01/01/2025
FQHCLA335C	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	01/01/2025
FQHCLA335A	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	04/01/2023
FQHCLA335B	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	01/01/2025
FQHCLA335D	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	01/01/2025
FQHCLA335E	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	10/10/2019
FQHCLA335E	LEE MEMORIAL HOSPITAL	2776 CLEVELAND AVE	ATTN: PHARMACY DEPARTMENT	FORT MYERS	FL	33901-5864	01/01/2018	10/01/2022
FQHCLA335D	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2018	01/01/2025
FQHCLA335C	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2018	01/01/2025
FQHCLA335E	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2018	10/01/2022
FQHCLA335A	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2018	04/01/2023
FQHCLA335B	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2018	01/01/2025
FQHCLA335	LEE PHARMACY #2	9981 S HEALTHPARK DR		FORT MYERS	FL	33908-3618	01/01/2020	01/01/2025
FQHCLA335	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/01/2023	01/01/2025
FQHCLA335	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2023	01/01/2025
FQHCLA335	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2024	01/01/2025
FQHCLA335	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	07/01/2023	01/01/2025
FQHCLA335	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/01/2023	01/01/2025
FQHCLA335	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/01/2022	01/01/2025
FQHCLA335	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	04/01/2022	01/01/2025
FQHCLA335	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/01/2022	01/01/2025
FQHCLA335	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/01/2022	01/01/2025
FQHCLA335	TOTAL HEALTHCARE ALLIANCE LLC	SOZO WELLNESS PHARMACY	3510 DR MARTIN LUTHER KING BLVD STE 1	FORT MYERS	FL	33916-4608	01/01/2023	01/01/2025
FQHCLA335AL	TOTAL HEALTHCARE ALLIANCE LLC	SOZO WELLNESS PHARMACY	3510 DR MARTIN LUTHER KING BLVD STE 1	FORT MYERS	FL	33916-4608	04/01/2024	01/01/2025

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2025 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		10/18/2024 12:00:00 AM	10/21/2024 9:21 AM
Details	State	Update	Termination Request	Active	To Be Terminated	10/21/2024 9:21 AM
Terminations	Termination Comments	Update	Termination Request		HRSA informed us on August 7th that the co-applicant agreement between Lee Health and Lee Community Healthcare would not be applicable under a new private not-for-profit business structure. After receiving affirmative votes from both boards, Lee Health and Lee Community Healthcare have decided to terminate the co-applicant agreement and FQHC-LA designation effective October 20th, 2024.	10/21/2024 9:21 AM
Terminations	Termination Date	Update	Termination Request		1/1/2025 12:00:00 AM	10/21/2024 9:21 AM
Terminations	Termination Effective Date	Update	Termination Request		10/20/2024 12:00:00 AM	10/21/2024 9:21 AM
Terminations	Termination Reason	Update	Termination Request		Business decision by the Covered Entity	10/21/2024 9:21 AM
Contacts	Authorizing Official	Update	Change Request	Johns, Robert Executive Director for Lee Community Healthcare Lee Community Healthcare 2398349998	Walter, Rachel Suzanne System Director, FQHC-LA Lee Health 2398235840	9/13/2024 8:03 AM
Details	Last Recertification Date	Update	Recertification		2/1/2024 2:05:52 PM	2/1/2024 2:05 PM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Johns, Robert Executive Director for Lee Community Healthcare Lee Community Healthcare 2398349998	10/16/2023 10:59 AM
Details	340B ID	Update	New Registration		FQHCLA335AN	10/16/2023 10:59 AM
Dates	Participating Approval Date	Update	New Registration		10/16/2023 10:59:20 AM	10/16/2023 10:59 AM
Details	State	Update	New Registration	Pending	Approved	10/16/2023 10:59 AM
Dates	Signed By Date	Update	New Registration		10/9/2023 1:49:12 PM	10/16/2023 10:59 AM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/16/2023 10:59 AM
Addresses	Main Address	Insert	New Registration		1569 Matthew Dr Fort Myers, FL 33907-1701	10/9/2023 1:49 PM
Contacts	Authorizing Official	Insert	New Registration		Johns, Robert Executive Director for Lee Community Healthcare Lee Community Healthcare 2398349998	10/9/2023 1:49 PM
Contacts	Primary Contact	Insert	New Registration		Bitner, Joseph Compliance Officer Lee Health 2393438602	10/9/2023 1:49 PM
Details	Assistance Received From Date	Insert	New Registration			10/9/2023 1:49 PM
Details	Assistance Received To Date	Insert	New Registration			10/9/2023 1:49 PM
Details	Last Recertification Date	Insert	New Registration			10/9/2023 1:49 PM
Details	Grant Number	Insert	New Registration		LALCS00171	10/9/2023 1:49 PM
Details	340B ID	Insert	New Registration			10/9/2023 1:49 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/9/2023 1:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/9/2023 1:49 PM
Details	Medicare Provider Number	Insert	New Registration			10/9/2023 1:49 PM
Details	Entity Name	Insert	New Registration		LEE MEMORIAL HEALTH SYSTEM	10/9/2023 1:49 PM
Details	NOFO Number	Insert	New Registration			10/9/2023 1:49 PM
Details	Program Code	Insert	New Registration		FQHCLA	10/9/2023 1:49 PM
Details	Entity Subname	Insert	New Registration		Internal Medicine Office Matthew Drive	10/9/2023 1:49 PM
Dates	Participating Approval Date	Insert	New Registration			10/9/2023 1:49 PM
Details	State	Insert	New Registration		Pending	10/9/2023 1:49 PM
Dates	Registration Date	Insert	New Registration		10/9/2023 1:49:09 PM	10/9/2023 1:49 PM
Dates	Signed By Date	Insert	New Registration			10/9/2023 1:49 PM
Dates	Start Date	Insert	New Registration			10/9/2023 1:49 PM
Terminations	Termination Comments	Insert	New Registration			10/9/2023 1:49 PM
Terminations	Termination Date	Insert	New Registration			10/9/2023 1:49 PM
Terminations	Termination Effective Date	Insert	New Registration			10/9/2023 1:49 PM
Terminations	Termination Reason	Insert	New Registration			10/9/2023 1:49 PM

340B Drug Pricing Program Database