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LEE MEMORIAL HEALTH SYSTEM
DSH100012Q LEE MEMORIAL HEALTH SYSTEM DBA LEE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LEE MEMORIAL HEALTH SYSTEM DBA LEE MEMORIAL HOSPITAL
Subdivision Name
Golisano Children's Hospital - Pediatrics
Type
Disproportionate Share Hospital
340B ID
DSH100012Q
Entity Address
9981 S. HealthPark Drive
Building 2 - Children's Hospital
Fort Myers, FL 33908
Medicare Provider Number
100012
Outpatient Facility Provider Number
Participating Start Date
1/1/2018
Last Recertification Date
8/19/2020
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
LEE MEMORIAL HEALTH SYSTEM
Pharmacy Address
EMPLOYEE PHARMACY
636 DEL PRADO BLVD S
SUTE 4 MOB
CAPE CORAL, FL 33990-2668
Pharmacy Comments
Contract Details
Approval Date
10/23/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Benjamin Spence, CFO
(239) 343-6014
Contract Pharmacy Representative
Lee Health
John Armistead, System Director Pharmacy
(239) 343-6490
Signed By Date
10/13/2017
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