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PHC PHARMACY, LLC
STD33009 Lifeline Health, Inc.
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Covered Entity Details
Entity Name
Lifeline Health, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD33009
Entity Address
501 Federal Highway 1
Lake Park, FL 33403
Grant Number
NH25PS005131
Participating Start Date
7/1/2019
Last Recertification Date
5/26/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
PHC PHARMACY, LLC
Pharmacy Address
PALM PARTNERS
1177 GEORGE BUSH BLVD
DELRAY BEACH, FL 33483-3348
Pharmacy Comments
Contract Details
Approval Date
5/14/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gary G Kogan, Executive Director
(888) 752-2267
Contract Pharmacy Representative
PHC Pharmacy
Konstantin Braverman, General Manager
(718) 928-8422
Signed By Date
4/12/2019
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