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866 EAST TREMONT PHARMACY LLC
RWI06605 LifeBridge Community Services, Inc.
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Covered Entity Details
Entity Name
LifeBridge Community Services, Inc.
Subdivision Name
Type
Ryan White Part A
340B ID
RWI06605
Entity Address
475 Clinton Avenue
Bridgeport, CT 06605
Grant Number
H89HA00029
Participating Start Date
10/1/2020
Last Recertification Date
Entity Termination Date
4/1/2021
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
8/4/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alan J Mathis, President & CEO
(203) 368-5517
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
7/15/2020
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