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WINN-DIXIE STORES INC
CH043823M BREVARD HEALTH ALLIANCE INC., THE
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Covered Entity Details
Entity Name
BREVARD HEALTH ALLIANCE INC., THE
Subdivision Name
BHA Sarno Regional Clinic
Type
HRSA-Funded Health Center
340B ID
CH043823M
Entity Address
2120 Sarno Road, Ste 2120
Melbourne, FL 32935
Grant Number
H80CS04213
Participating Start Date
7/1/2013
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WINN-DIXIE STORES INC
Pharmacy Address
WINN-DIXIE PHARMACY #2327
1535 N SINGLETON AVE
TITUSVILLE, FL 32796
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/24/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Richard Austin Helton, CEO
(321) 241-6868
Contract Pharmacy Representative
Winn Dixie
David Chism, Senior Director
(904) 370-6455
Signed By Date
4/11/2019
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