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PREVENT RX,
STD33009 Lifeline Health, Inc.
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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
PREVENT RX,
Pharmacy Address
2925 10TH AVE., N., STE 108
PALM SPRINGS, FL 33461
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/3/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gary G Kogan, Executive Director
(888) 752-2267
Contract Pharmacy Representative
Prevent RX
Mina Banoub, Pharmacy Department Manager
(844) 978-3186
Signed By Date
7/15/2022
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