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AVITA PHARMACY 1047
CH04023J AGAPE COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
AGAPE COMMUNITY HEALTH CENTER, INC.
Subdivision Name
AGAPE/Magnolia Jacksonville Community Health Center
Type
HRSA-Funded Health Center
340B ID
CH04023J
Entity Address
5300 N Pearl Street
Jacksonville, FL 32208
Grant Number
H80CS29456
Participating Start Date
10/1/2016
Last Recertification Date
1/29/2019
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1047
Pharmacy Address
AVITA DRUGS FLORIDA LLC D/B/A AVITA PHAR
801 N MAGNOLIA AVE STE 406
ORLANDO, FL 32803-3843
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mia L. Jones, CEO
(904) 760-4910
Contract Pharmacy Representative
Avita Pharmacy
Roland Hewitt, Account Executive
(407) 866-3283
Signed By Date
4/12/2019
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