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WALMART PHARMACY 10-5169
STD338251 J AGUSTIN LACSON MD INC
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Covered Entity Details
Entity Name
J AGUSTIN LACSON MD INC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD338251
Entity Address
3300 US 27 SOUTH
AVON PARK, FL 33825
Grant Number
NH25PS005131
Participating Start Date
8/12/2020
Last Recertification Date
5/10/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
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
agustin juan lacson, president
(863) 835-0060
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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