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BRIOVARX OF MAINE INC
STD336141 CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
Habana
Type
Sexually Transmitted Diseases
340B ID
STD336141
Entity Address
4729 N Habana Ave
Tampa, FL 33614
Grant Number
1 NH25PS005131-01-00
Participating Start Date
4/1/2016
Last Recertification Date
6/3/2025
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
10/22/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Richard E. Carlisle, President & CEO
(941) 366-0134 Ext: 11111
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
10/22/2018
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