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CORAM HEALTHCARE CORPORATION OF FLORIDA
DSH100022 JACKSON HEALTH SYSTEM
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Covered Entity Details
Entity Name
JACKSON HEALTH SYSTEM
Subdivision Name
JACKSON MEMORIAL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH100022
Entity Address
1611 NW 12 AVE.
MIAMI, FL 33136
Medicare Provider Number
100022
Participating Start Date
12/1/1992
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
CORAM HEALTHCARE CORPORATION OF FLORIDA
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
8508 BENJAMIN RD
SUITE C
TAMPA, FL 33634-1241
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/11/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carlos A. Migoya, CEO
(305) 585-6754
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/12/2018
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