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AVITA PHARMACY 1047
CH04023L AGAPE COMMUNITY HEALTH CENTER South
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Covered Entity Details
Entity Name
AGAPE COMMUNITY HEALTH CENTER South
Subdivision Name
Agape Community Health Center, Inc
Type
HRSA-Funded Health Center
340B ID
CH04023L
Entity Address
3900 University Blvd S
Jacksonville, FL 32216-4395
Grant Number
H80CS29456
Participating Start Date
4/1/2017
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1047
Pharmacy Address
AVITA DRUGS FLORIDA LLC D/B/A AVITA PHAR
1110 KEVSTIN DR
KISSIMMEE, FL 34744
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tabatha Ball, COO
(904) 760-4904
Contract Pharmacy Representative
Avita Pharmacy
Roland Hewitt, Account Executive
(407) 866-3283
Signed By Date
4/9/2019
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