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Walgreens #21395
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
5/6/2024
Pharmacy Details
Pharmacy Name
Walgreens #21395
Pharmacy Address
Walgreens Central Fill #21395
5710 Young Pine Rd
Orlando, FL 32829
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2024
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