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MELROSE PHARMACY
STD850152 CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
Medical Mobile Unit of Arizona
Type
Sexually Transmitted Diseases
340B ID
STD850152
Entity Address
4350 N 19th Avenue
Suite 2
Phoenix, AZ 85015
Grant Number
6 NU62PS924818-01-01
Participating Start Date
1/1/2020
Last Recertification Date
5/27/2024
Pharmacy Details
Pharmacy Name
MELROSE PHARMACY
Pharmacy Address
706 W. MONTECITO AVE
PHOENIX, AZ 85013
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard E. Carlisle, President & CEO
(941) 366-0134 Ext: 11111
Contract Pharmacy Representative
Melrose Pharmacy
Teresa Stickler, Owner
(602) 277-4714
Signed By Date
10/15/2020
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