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LEE MEMORIAL HEALTH SYSTEM
FQHCLA335D LEE MEMORIAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
LEE MEMORIAL HEALTH SYSTEM
Subdivision Name
East Fort Myers Ob/Gyn Medical Office
Type
Health Center Program Look-Alike
340B ID
FQHCLA335D
Entity Address
4040 Palm Beach Boulevard, Suite F
Fort Myers, FL 33916-3470
Grant Number
LALCS00171
Participating Start Date
1/1/2018
Last Recertification Date
1/29/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
LEE MEMORIAL HEALTH SYSTEM
Pharmacy Address
LEE PHARMACY 3
13681 DOCTORS WAY
FORT MYERS, FL 33912
Pharmacy Comments
Contract Details
Approval Date
10/24/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robert Johns, Executive Director for Lee Community Healthcare
(239) 834-9998
Contract Pharmacy Representative
Lee Memorial Health System
Anson Phetteplace, Pharmacy Supervisor for Lee Memorial Health System
(239) 343-2821
Signed By Date
10/16/2017
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