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866 EAST TREMONT PHARMACY LLC
STD39202 Magnolia Medical Foundation
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Covered Entity Details
Entity Name
Magnolia Medical Foundation
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD39202
Entity Address
256 East Fortification St.
Jackson, MS 39202
Grant Number
6NU62PS924746-02-01
Participating Start Date
2/22/2023
Last Recertification Date
5/14/2024
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
2/22/2023
Contract Begin Date
2/22/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Erica Thompson, Executive Director
(769) 524-8002 Ext: 1003
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
1/13/2023
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