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866 EAST TREMONT PHARMACY LLC
RWI89102 Horizon Ridge Clinic LLC
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Covered Entity Details
Entity Name
Horizon Ridge Clinic LLC
Subdivision Name
Type
Ryan White Part A
340B ID
RWI89102
Entity Address
1670 E Flamingo Road
Suite A
Las Vegas, NV 89119
Grant Number
H89HA06900
Participating Start Date
7/1/2018
Last Recertification Date
2/2/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
866 EAST TREMONT PHARMACY LLC
Pharmacy Address
BOCA PHARMACY
864B E TREMONT AVE
BRONX, NY 10460
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bruce Eddins, Chief Administrator
(702) 489-2889 Ext: 102
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
4/9/2019
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