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PENNSYLVANIA CVS PHARMACY, L.L.C.
RW424852A Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Type
Ryan White Part D
340B ID
RW424852A
Entity Address
1348 Bainbridge Street
Philadelphia, PA 19147-1810
Grant Number
H12HA24852
Participating Start Date
10/1/2016
Last Recertification Date
2/16/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02583
421 SOUTH SECOND ST.
PHILADELPHIA, PA 19147
Pharmacy Comments
Contract Details
Approval Date
10/8/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/16/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ronald Powers, COO
(215) 563-0652 Ext: 210
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/8/2018
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