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HOLIDAY CVS, L.L.C.
DSH100175 DESOTO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DESOTO MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100175
Entity Address
900 NORTH ROBERT AVENUE
ARCADIA, FL 34266
Medicare Provider Number
100175
Participating Start Date
1/1/2008
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03107
24 S. BREVARD AVE.
ARCADIA, FL 34266
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel P. Hogan, CFO
(863) 494-8414
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/15/2019
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