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HOLIDAY CVS, L.L.C.
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
5/10/2024
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02030
301 S. 6TH AVE.
WAUCHULA, FL 33873
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
5/9/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
agustin juan lacson, president
(863) 835-0060
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/14/2022
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