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VISTA MEDICAL GROUP LLC
RWII33511 CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII33511
Entity Address
214 Morrison Road
Suite 104
Brandon, FL 33511
Grant Number
X07HA00057
Participating Start Date
10/1/2014
Last Recertification Date
2/20/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
VISTA MEDICAL GROUP LLC
Pharmacy Address
MEDICASCRIPTS PHARMACY
15511 N. FLORIDA AVE
TAMPA, FL 33613
Pharmacy Comments
Contract Details
Approval Date
7/14/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/13/2018
Ownership change
Contacts
Covered Entity Signing Official
Richard E. Carlisle, President & CEO
(941) 366-0461 Ext: 11111
Contract Pharmacy Representative
Bhavik Patel, owner
(813) 968-0520
Signed By Date
7/14/2016
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