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WINN DIXIE PHARMACY #2230
CH043823R BREVARD HEALTH ALLIANCE, INC., THE
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Covered Entity Details
Entity Name
BREVARD HEALTH ALLIANCE, INC., THE
Subdivision Name
BHA Evans Center Clinic
Type
HRSA-Funded Health Center
340B ID
CH043823R
Entity Address
1361 Florida Ave NE
STE 2
Palm Bay, FL 32905-2650
Grant Number
H80CS04213
Participating Start Date
4/1/2019
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WINN DIXIE PHARMACY #2230
Pharmacy Address
190 MALABAR RD SW
PALM BAY, FL 32907
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/28/2023
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
4/15/2019
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