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AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
STD331383 Pridelines Youth Services, Inc
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Covered Entity Details
Entity Name
Pridelines Youth Services, Inc
Subdivision Name
Pridelines
Type
Sexually Transmitted Diseases
340B ID
STD331383
Entity Address
1130 Washington Avenue
1st Floor North
Miami Beach, FL 33139
Grant Number
NU62PS924532
Participating Start Date
10/1/2022
Last Recertification Date
5/21/2025
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
1/11/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Victor Diaz-Herman, CEO
(305) 571-9601
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
1/11/2024
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