Contract Pharmacy Details

HOLIDAY CVS, L.L.C.
RRC100307-00 ST. VINCENTS MEDICAL CENTER SOUTHSID

Covered Entity Details

Entity Name

ST. VINCENTS MEDICAL CENTER SOUTHSID

Subdivision Name

Type

Rural Referral Center

340B ID

RRC100307-00

Entity Address

4201 BELFORT ROAD
JACKSONVILLE, FL 32216

Medicare Provider Number

100307

Participating Start Date

10/1/2020

Last Recertification Date

8/20/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

HOLIDAY CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05254
4280 SOUTHSIDE BLVD
JACKSONVILLE, FL 32216

Pharmacy Comments

Contract Details

Approval Date

7/20/2021

Contract Begin Date

10/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Susan Cornejo, Chief Operating Officer
(850) 416-6206

Contract Pharmacy Representative

Caremark L.L.C.
Christian reid, 340b Program Director
(401) 770-2118

Signed By Date

7/20/2021

340B Drug Pricing Program Database