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WICKHAM DISCOUNT PHARMACY LLC
CH043823A BREVARD HEALTH ALLIANCE INC., THE
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Covered Entity Details
Entity Name
BREVARD HEALTH ALLIANCE INC., THE
Subdivision Name
BHA Melbourne Clinic
Type
HRSA-Funded Health Center
340B ID
CH043823A
Entity Address
17 Silver Palm Avenue
Melbourne, FL 32901-3123
Grant Number
H80CS04213
Participating Start Date
4/1/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WICKHAM DISCOUNT PHARMACY LLC
Pharmacy Address
WICKHAM PHARMACY
1060 N. WICKHAM RD
MELBOURNE, FL 32935-8937
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/18/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Austin Helton, CEO
(321) 241-6854
Contract Pharmacy Representative
Wickham Discount Pharmacy LLC
Ankit Shah, Owner/Pharmacist
(321) 626-2679
Signed By Date
4/14/2022
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