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NORTH SHORE HEALTH MART PHARMACY
STD16508 Central Outreach Wellness Center, LLC
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Covered Entity Details
Entity Name
Central Outreach Wellness Center, LLC
Subdivision Name
Central Outreach Wellness Center, LLC Erie
Type
Sexually Transmitted Diseases
340B ID
STD16508
Entity Address
3104 State Street
Erie, PA 16508
Grant Number
NH25PS005144
Participating Start Date
1/1/2021
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
NORTH SHORE HEALTH MART PHARMACY
Pharmacy Address
MEMAW, INC D/B/A:
127 ANDERSON ST STE 101
PITTSBURGH, PA 15212-5803
Pharmacy Comments
Contract Details
Approval Date
11/10/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stacy Lane, Owner
(412) 608-8313
Contract Pharmacy Representative
Northshore Pharmacy
Patrick Davis, owner
(412) 889-2311
Signed By Date
10/2/2020
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