Contract Pharmacy Details

HOLIDAY CVS, L.L.C.
FQHCLA430 MENTAL HEALTH CARE, INC.

Covered Entity Details

Entity Name

MENTAL HEALTH CARE, INC.

Subdivision Name

Gracepoint Wellness Clinic

Type

Health Center Program Look-Alike

340B ID

FQHCLA430

Entity Address

5707 N. 22nd Street
Tampa, FL 33610-4350

Grant Number

LALCS40297

Participating Start Date

1/1/2022

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

HOLIDAY CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03638
10623 GIBSONTON DR
RIVERVIEW, FL 33578

Pharmacy Comments

Contract Details

Approval Date

7/15/2022

Contract Begin Date

10/1/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Roaya Tyson, CEO
(813) 965-2630

Contract Pharmacy Representative

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

Signed By Date

7/15/2022

340B Drug Pricing Program Database