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LIFE TREE PHARMACY BROUSSARD
STD71105 Merakey Pennsylvania-Shreveport
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Covered Entity Details
Entity Name
Merakey Pennsylvania-Shreveport
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD71105
Entity Address
8932 Jewella Ave, Ste. A
Shreveport, LA 71118
Grant Number
6 NH25PS005176-02-03
Participating Start Date
1/1/2021
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
LIFE TREE PHARMACY BROUSSARD
Pharmacy Address
120 PARK CENTER DR
BROUSSARD, LA 70518-3605
Pharmacy Comments
Contract Details
Approval Date
11/20/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph S Martz, CEO
(215) 341-9395
Contract Pharmacy Representative
Life Tree Pharmacy
Mark Taglianetti, CEO
(610) 489-6640
Signed By Date
10/15/2020
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