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PENNSYLVANIA CVS PHARMACY, L.L.C.
STD19147 Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
STD Services
Type
Sexually Transmitted Diseases
340B ID
STD19147
Entity Address
1348 Bainbridge Street
PHILADELPHIA, PA 19147
Grant Number
6NU62PS924545
Participating Start Date
10/1/2018
Last Recertification Date
5/9/2024
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
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2020
Agreement registered in error
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
10/11/2018
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