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AETNA SPECIALTY PHARMACY, LLC
CH063250 El Centro Del Barrio
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Covered Entity Details
Entity Name
El Centro Del Barrio
Subdivision Name
CentroMed Southside Medical Clinic
Type
HRSA-Funded Health Center
340B ID
CH063250
Entity Address
3750 Commercial Ave
San Antonio, TX 78221-3117
Grant Number
H80CS00758
Participating Start Date
12/1/1992
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AETNA SPECIALTY PHARMACY, LLC
Pharmacy Address
503 SUNPORT LN
ORLANDO, FL 32809-7874
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Ernesto Gomez, President / CEO
(210) 334-3703
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/11/2019
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