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PREVENT RX
STD321143 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
STD321143
Entity Address
211 N. Ridgewood Ave
114-115
Daytona Beach, FL 32114
Grant Number
NH25PS005131
Participating Start Date
8/18/2020
Last Recertification Date
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
PREVENT RX
Pharmacy Address
906 W SUNRISE BLVD
STE B
FORT LAUDERDALE, FL 33311
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
7/15/2020
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