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HOLIDAY CVS, L.L.C.
PED103301-00 Nicklaus Children's Hospital
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Covered Entity Details
Entity Name
Nicklaus Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED103301-00
Entity Address
3100 SW 62nd Avenue
Miami, FL 33155
Medicare Provider Number
103301
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 10131
2393 SW 67TH AVE.
MIAMI, FL 33155
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jose Perdomo, Interim President and COO
(305) 666-6511 Ext: 2010
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2019
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