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870 SOUTHERN DRUG CORP
STD10018 Gay Men's Health Crisis, Inc. (GMHC)
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Covered Entity Details
Entity Name
Gay Men's Health Crisis, Inc. (GMHC)
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD10018
Entity Address
307 W. 38th Street
New York, NY 10018
Grant Number
6NH25PS005177
Participating Start Date
7/1/2021
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
870 SOUTHERN DRUG CORP
Pharmacy Address
D/B/A AVITA PHARMACY 1064
924 MYRTLE AVE
BROOKLYN, NY 11206
Pharmacy Comments
Contract Details
Approval Date
5/19/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kelsey Louie, CEO
(212) 367-1248
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/12/2021
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