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PREVENT RX 2
STD322504 Positive Health Alliance, Inc.
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Covered Entity Details
Entity Name
Positive Health Alliance, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD322504
Entity Address
91 12th Street South
Jacksonville Beach, FL 32250
Grant Number
NH25PS005131
Participating Start Date
8/18/2020
Last Recertification Date
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
PREVENT RX 2
Pharmacy Address
3677 CENTRAL AVE
STE-A
FORT MYERS, FL 33901
Pharmacy Comments
Contract Details
Approval Date
8/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary G Kogan, Executive Director
(888) 752-2267
Contract Pharmacy Representative
UNITED PHARMACY
ANDY TRIGGS, MANAGER
(855) 445-4401 Ext: 121
Signed By Date
7/1/2020
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