Contract Pharmacy Details

LAKE TOWN PHARMACY
CH040250 PROJECT HEALTH, INC

Covered Entity Details

Entity Name

PROJECT HEALTH, INC

Subdivision Name

THOMAS E. LANGLEY MEDICAL CENTER

Type

HRSA-Funded Health Center

340B ID

CH040250

Entity Address

1389 SOUTH US HIGHWAY 301
SUMTERVILLE, FL 33585

Grant Number

H80CS00412

Participating Start Date

12/1/1992

Last Recertification Date

2/17/2025

Pharmacy Details

Pharmacy Name

LAKE TOWN PHARMACY

Pharmacy Address

2020 N CR 470
UNIT-B
LAKE PANASOFFKEE, FL 33538

Pharmacy Comments

Contract Details

Approval Date

10/26/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Gary Costantino, CFO
(352) 793-5900

Contract Pharmacy Representative

Raj Mani, Pharmacy Manager
(352) 444-2055

Signed By Date

10/26/2016