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WAL-MART PHARMACY 10-0666
STD338251 J AGUSTIN LACSON MD INC
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Covered Entity Details
Entity Name
J AGUSTIN LACSON MD INC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD338251
Entity Address
3300 US 27 SOUTH
AVON PARK, FL 33825
Grant Number
NH25PS005131
Participating Start Date
8/12/2020
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0666
Pharmacy Address
3525 U.S. HWY 27 NORTH
SEBRING, FL 33870
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
agustin juan lacson, president
(863) 835-0060
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/14/2021
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