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PREVENT RX
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
PREVENT RX
Pharmacy Address
906 W SUNRISE BLVD
STE B
FORT LAUDERDALE, FL 33311
Pharmacy Comments
Contract Details
Approval Date
1/23/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/2/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gary G Kogan, Executive Director
(888) 752-2267
Contract Pharmacy Representative
Prevent RX
Mina Banoub, Pharmacy Department Manager
(844) 978-3186
Signed By Date
1/23/2020
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