Contract Pharmacy Details

PROCARE PHARMACY, L.L.C.
STD33009 Lifeline Health, Inc.

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

PROCARE PHARMACY, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203

Pharmacy Comments

Contract Details

Approval Date

7/14/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/4/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Gary G Kogan, Executive Director
(888) 752-2267

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/14/2020

340B Drug Pricing Program Database