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PICH KTM CORP
CH042063A SULZBACHER, I M CENTER FOR THE HOMELESS INC, THE
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Covered Entity Details
Entity Name
SULZBACHER, I M CENTER FOR THE HOMELESS INC, THE
Subdivision Name
Beaches Community Healthcare - A Sulzbacher Center Clinic
Type
HRSA-Funded Health Center
340B ID
CH042063A
Entity Address
850 Sixth Avenue STE 500
Jacksonville Beach, FL 32250
Grant Number
H80CS00305
Participating Start Date
1/1/2016
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
PICH KTM CORP
Pharmacy Address
DBA MEDTOWN PHARMACY
11643 BEACH BLVD
UNIT A
JACKSONVILLE, FL 32246
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
12/7/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cindy Funkhouser, CEO
(904) 394-8069
Contract Pharmacy Representative
Medtown Pharmacy
Nakry Oeur, Owner
(904) 551-5870
Signed By Date
10/16/2023
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