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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA WALGREENS #16543
5555 PONCE DE LEON BLVD.
SUITE 186
CORAL GABLES, FL 33146
Pharmacy Comments
Contract Details
Approval Date
4/3/2020
Contract Begin Date
7/1/2020
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/3/2020
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