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AZ PHARMACY, LLC
CH051828E NORTHSHORE HEALTH CENTERS, INC
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Covered Entity Details
Entity Name
NORTHSHORE HEALTH CENTERS, INC
Subdivision Name
NorthShore/Regional Health Center
Type
HRSA-Funded Health Center
340B ID
CH051828E
Entity Address
8555 Taft Street
Merrillville, IN 46410
Grant Number
H80CS02458
Participating Start Date
7/1/2013
Last Recertification Date
1/29/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
AZ PHARMACY, LLC
Pharmacy Address
DBA AMAZON PHARMACY #002
3809 E WATKINS ST
PHOENIX, AZ 85034
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JANICE WILSON, CEO
(219) 764-6052
Contract Pharmacy Representative
PillPack, Inc.
Geoff Swindle, Administrator
(855) 745-5725
Signed By Date
1/14/2019
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