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AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
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
AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
Pharmacy Address
8601 COMMODITY CIR, SUITE 105
ORLANDO, FL 32819-9003
Pharmacy Comments
Contract Details
Approval Date
10/7/2022
Contract Begin Date
10/17/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary Kogan, Director
(786) 877-7001
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/7/2022
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