Contract Pharmacy Details

866 EAST TREMONT PHARMACY LLC
RWI98032 UTOPIA Washington

Covered Entity Details

Entity Name

UTOPIA Washington

Subdivision Name

Mapu Maia Clinic

Type

Ryan White Part A

340B ID

RWI98032

Entity Address

812 Central Ave N
Kent, WA 98032

Grant Number

H89HA00022

Participating Start Date

10/1/2024

Last Recertification Date

Entity Termination Date

4/1/2025

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

8/2/2023

Contract Begin Date

10/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Tepatasi Vaina, Ms.
(206) 653-1941

Contract Pharmacy Representative

Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700

Signed By Date

7/13/2023