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SAMSON MERGER SUB, LLC
RWIID32304 FLORIDA DEPARTMENT OF HEALTH
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Covered Entity Details
Entity Name
FLORIDA DEPARTMENT OF HEALTH
Subdivision Name
AIDS Drug Assistance Program (ADAP)
Type
Ryan White Part B ADAP Direct Purchase
340B ID
RWIID32304
Entity Address
4052 BALD CYPRESS WAY
BIN A-09
TALLAHASSEE, FL 32399
Grant Number
X07HA00057
Participating Start Date
1/1/2009
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
SAMSON MERGER SUB, LLC
Pharmacy Address
WINN DIXIE #2409
2139 34TH STREET NORTH
SAINT PETERSBURG, FL 33713
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
JIMMY ROGER LLAQUE, ADAP STATE PROGRAM DIRECTOR
(850) 545-6836
Contract Pharmacy Representative
Winn-Dixie Stores, Inc.
Gayle Shields, VP, Pharmacy
(904) 783-5000
Signed By Date
7/15/2022
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