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WALGREEN EASTERN CO INC
FQHCLA463 Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Washington West
Type
Health Center Program Look-Alike
340B ID
FQHCLA463
Entity Address
1201 Locust St.
Philadelphia, PA 19107-5409
Grant Number
LALCS52965
Participating Start Date
4/1/2024
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO INC
Pharmacy Address
DBA: WALGREENS # 04115
4201 N BROAD ST
PHILADELPHIA, PA 19140
Pharmacy Comments
Contract Details
Approval Date
3/11/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/30/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Alecia Manley, Executive Operating Officer
(215) 563-0652
Contract Pharmacy Representative
Walgreens
Cheryl Mullins, 340B Client Relationship Analysist
(847) 527-2432
Signed By Date
1/8/2024
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