Contract Pharmacy Details

PENNSYLVANIA CVS PHARMACY, L.L.C.
RWI19063B Mazzoni Center

Covered Entity Details

Entity Name

Mazzoni Center

Subdivision Name

Mazzoni Center Washington West Project Location

Type

Ryan White Part A

340B ID

RWI19063B

Entity Address

1201 Locust Street
Philadelphia, PA 19107

Grant Number

H89HA00013

Participating Start Date

10/1/2022

Last Recertification Date

2/17/2025

Pharmacy Details

Pharmacy Name

PENNSYLVANIA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 02583
421 SOUTH SECOND ST.
PHILADELPHIA, PA 19147

Pharmacy Comments

Contract Details

Approval Date

10/11/2022

Contract Begin Date

1/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/16/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Alecia Manley, Executive Operating Officer
(215) 563-0652

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/11/2022

340B Drug Pricing Program Database