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866 EAST TREMONT PHARMACY LLC
STD64106 BlaqOut, Inc.
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Covered Entity Details
Entity Name
BlaqOut, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD64106
Entity Address
517 Campbell Street
Kansas City, MO 64106
Grant Number
NH25PS005142
Participating Start Date
4/1/2020
Last Recertification Date
5/13/2024
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
2/19/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
D. Rashaan Gilmore, President/CEO
(816) 866-0355
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
1/14/2020
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