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WAL-MART PHARMACY 10-0666
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
5/7/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0666
Pharmacy Address
3525 U.S. HWY 27 NORTH
SEBRING, FL 33870
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
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
11/30/2022
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