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Walgreens #21395
DSH100307 ASCENSION ST. VINCENTS SOUTHSIDE HO
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Covered Entity Details
Entity Name
ASCENSION ST. VINCENTS SOUTHSIDE HO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100307
Entity Address
4201 BELFORT ROAD
JACKSONVILLE, FL 32216
Medicare Provider Number
100307
Participating Start Date
1/21/2025
Last Recertification Date
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
4/11/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Contract Pharmacy Representative
Walgreens
Ruthann Archer, Director of 340B Operations
(847) 964-8116
Signed By Date
4/11/2025
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