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IC PHARMACY LLC
CH01241F STAYWELL HEALTH CARE, INC.
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Covered Entity Details
Entity Name
STAYWELL HEALTH CARE, INC.
Subdivision Name
Wallace School Based Health Center
Type
HRSA-Funded Health Center
340B ID
CH01241F
Entity Address
3465 E Main St
Waterbury, CT 06705-3815
Grant Number
H80CS00350
Participating Start Date
4/1/2015
Last Recertification Date
2/16/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
IC PHARMACY LLC
Pharmacy Address
AMAZON PHARMACY #004
34 35TH STREET
STE 4BSW, UNIT 28
BROOKLYN, NY 11232
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/29/2023
OPA Terminated due to audit finding
Contacts
Covered Entity Signing Official
Donald Thompson, CEO
(203) 756-8021 Ext: 3016
Contract Pharmacy Representative
PillPack, Inc.
Geoff Swindle, Administrator
(855) 745-5725
Signed By Date
7/15/2020
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