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HOLIDAY CVS, L.L.C.
STD338801 J AGUSTIN LACSON MD INC
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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
5/10/2024
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 05410
4478 TAMIAMI TRAIL
PORT CHARLOTTE, FL 33980
Pharmacy Comments
Contract Details
Approval Date
2/3/2023
Contract Begin Date
2/3/2023
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
11/30/2022
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