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MEDLY PHARMACY INC.
FQHCLA412 Lasante Health Center, Inc.
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Covered Entity Details
Entity Name
Lasante Health Center, Inc.
Subdivision Name
Lasante Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA412
Entity Address
672 Parkside Ave
Brooklyn, NY 11226-1506
Grant Number
LALCS31598
Participating Start Date
1/1/2021
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
MEDLY PHARMACY INC.
Pharmacy Address
DBA MEDLY PHARMACY
31 DEBEVOISE ST
BROOKLYN, NY 11206-4196
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/10/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mordechai Heller, COO
(718) 246-5700 Ext: 120
Contract Pharmacy Representative
Medly Pharmacy
Jitendra Patel, Pharmacy Director
(718) 782-7539
Signed By Date
1/14/2021
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