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LEE MEMORIAL HEALTH SYSTEM
FQHCLA335E LEE MEMORIAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
LEE MEMORIAL HEALTH SYSTEM
Subdivision Name
South Fort Myers Ob/Gyn Medical Office
Type
Health Center Program Look-Alike
340B ID
FQHCLA335E
Entity Address
9800 S. Healthpark Dr.
Suite 205
Fort Myers, FL 33908
Grant Number
LALCS00171
Participating Start Date
1/1/2018
Last Recertification Date
1/31/2022
Entity Termination Date
10/1/2022
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
10/1/2022
Covered Entity Terminated
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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