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AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
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
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
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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