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PREVENT RX,
STD335632 Lifeline Health, Inc.
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Covered Entity Details
Entity Name
Lifeline Health, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD335632
Entity Address
2005 W. Reynolds St
Plant City, FL 33563
Grant Number
NH25PS005131
Participating Start Date
8/18/2020
Last Recertification Date
5/19/2025
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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