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866 EAST TREMONT PHARMACY LLC
STD85719 Southern Arizona AIDS Foundation
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Covered Entity Details
Entity Name
Southern Arizona AIDS Foundation
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD85719
Entity Address
375 S Euclid
Tucson, AZ 85719
Grant Number
NU62PS924675-01-00
Participating Start Date
1/1/2022
Last Recertification Date
5/21/2025
Pharmacy Details
Pharmacy Name
866 EAST TREMONT PHARMACY LLC
Pharmacy Address
BOCA PHARMACY
864B E TREMONT AVE
BRONX, NY 10460
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
5/9/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ravi Grivois-Shah, CEO
(520) 547-6096
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
4/15/2022
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