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Walgreens #21395
STD342661 J AGUSTIN LACSON MD INC
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Covered Entity Details
Entity Name
J AGUSTIN LACSON MD INC
Subdivision Name
ARCADIA
Type
Sexually Transmitted Diseases
340B ID
STD342661
Entity Address
1709 EAST OAK STREET
ARCADIA, FL 34266
Grant Number
NH25PS005131
Participating Start Date
11/17/2021
Last Recertification Date
5/10/2024
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
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
agustin juan lacson, president
(863) 835-0060
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2023
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