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EZ RX HALLANDALE LLC
STD33054 Community Life Support
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Covered Entity Details
Entity Name
Community Life Support
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD33054
Entity Address
486-490 Fisherman Street,
Opalocka, FL 33054
Grant Number
NH25PS004342-04-01
Participating Start Date
1/1/2020
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
EZ RX HALLANDALE LLC
Pharmacy Address
1550 W 84TH ST STE 62
HIALEAH, FL 33014-3379
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PIERRE R. BLEMUR, M.D.
(305) 688-5456
Contract Pharmacy Representative
EZRX PHARMACY
MIRTHA GONZALEZ, PHARMACY TECH
(786) 259-3076
Signed By Date
7/11/2024
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