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LIFE TREE PHARMACY
RWI071020 St James Social Service Corp.
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Covered Entity Details
Entity Name
St James Social Service Corp.
Subdivision Name
Type
Ryan White Part A
340B ID
RWI071020
Entity Address
604 DR. MLK. Blvd
Newark, NJ 07102
Grant Number
H89HA00003
Participating Start Date
10/1/2018
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
LIFE TREE PHARMACY
Pharmacy Address
5 BLUE HERON DRIVE
COLLEGEVILLE, PA 19426
Pharmacy Comments
Contract Details
Approval Date
8/27/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Zhan LaQuerDouglas, Health Wellness Asst.
(973) 624-4007
Contract Pharmacy Representative
Life Tree Pharmacy
Mark Taglianetti, CEO
(610) 489-6640
Signed By Date
7/17/2018
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