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AVITA PHARMACY 1047
STD349721 Midway Specialty Care Center Inc
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Covered Entity Details
Entity Name
Midway Specialty Care Center Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD349721
Entity Address
113 NE 19TH DRIVE
OKEECHOBEE, FL 34972
Grant Number
NH25PS005131
Participating Start Date
10/1/2018
Last Recertification Date
5/12/2020
Entity Termination Date
1/1/2021
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
4/13/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kathryn E Hayden, CFO
(772) 742-9276
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/13/2019
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