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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05947
3027 US HWY 27 SOUTH
SEBRING, FL 33870
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2022
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