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LEE MEMORIAL HEALTH SYSTEM
DSH100012A LEE MEMORIAL HEALTH SYSTEM DBA LEE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LEE MEMORIAL HEALTH SYSTEM DBA LEE MEMORIAL HOSPITAL
Subdivision Name
HEALTHPARK MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH100012A
Entity Address
9981 S. HEALTH PARK DRIVE
FORT MYERS, FL 33908
Medicare Provider Number
100012
Outpatient Facility Provider Number
Participating Start Date
4/1/2009
Last Recertification Date
8/19/2020
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
LEE MEMORIAL HEALTH SYSTEM
Pharmacy Address
EMPLOYEE PHARMACY
636 DEL PRADO BLVD S
SUTE 4 MOB
CAPE CORAL, FL 33990-2668
Pharmacy Comments
Contract Details
Approval Date
10/5/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Benjamin Spence, CFO
(239) 343-6014
Contract Pharmacy Representative
Lee Memorial Health System
Diane Bush, Pharmacy Supervisor
(239) 424-3157
Signed By Date
10/5/2018
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