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HOLIDAY CVS, L.L.C.
DSH100022 JACKSON HEALTH SYSTEM
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Covered Entity Details
Entity Name
JACKSON HEALTH SYSTEM
Subdivision Name
JACKSON MEMORIAL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH100022
Entity Address
1611 NW 12 AVE.
MIAMI, FL 33136
Medicare Provider Number
100022
Participating Start Date
12/1/1992
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05897
3700 NW 199TH ST.
MIAMI GARDENS, FL 33055
Pharmacy Comments
Contract Details
Approval Date
4/20/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carlos A. Migoya, CEO
(305) 585-6754
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/20/2022
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