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AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
STD330201 Lifeline Health, Inc.
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Covered Entity Details
Entity Name
Lifeline Health, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD330201
Entity Address
1311 North Federal Highway
Hollywood, FL 33020
Grant Number
NH25PS005131
Participating Start Date
4/1/2024
Last Recertification Date
5/20/2025
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
2/26/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/7/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Gary Kogan, Director
(786) 877-7001
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
1/9/2024
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