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GENOA HEALTHCARE LLC
STD336073 Healthy MD Clinical, LLC (f.k.a. Independent Medical Group, LLC)
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Covered Entity Details
Entity Name
Healthy MD Clinical, LLC (f.k.a. Independent Medical Group, LLC)
Subdivision Name
Lakeland
Type
Sexually Transmitted Diseases
340B ID
STD336073
Entity Address
3900 S. Florida Avenue
Suite 205
Lakeland, FL 33813
Grant Number
NH25PS004342-04-01
Participating Start Date
1/1/2021
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
12512 BRUCE B DOWNS BLVD STE A142
TAMPA, FL 33612
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
10/31/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/17/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve Vixamar, COO
(954) 529-1178
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2021
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