Contract Pharmacy Details

HOLIDAY CVS, L.L.C.
STD338801 J AGUSTIN LACSON MD INC

Covered Entity Details

Entity Name

J AGUSTIN LACSON MD INC

Subdivision Name

WINTER HAVEN

Type

Sexually Transmitted Diseases

340B ID

STD338801

Entity Address

537 E CENTRAL AVE
STE B
WINTER HAVEN, FL 33880-3001

Grant Number

NH25PS005131

Participating Start Date

2/3/2023

Last Recertification Date

5/7/2025

Pharmacy Details

Pharmacy Name

HOLIDAY CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 02444
1105 W MAIN ST
AVON PARK, FL 33825

Pharmacy Comments

Contract Details

Approval Date

2/3/2023

Contract Begin Date

2/3/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/30/2023
Pharmacy closed

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

11/30/2022

340B Drug Pricing Program Database