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Walgreens #21395
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
Walgreens #21395
Pharmacy Address
Walgreens Central Fill #21395
5710 Young Pine Rd
Orlando, FL 32829
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carlos A. Migoya, CEO
(305) 585-6754
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/17/2023
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