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CYSTIC FIBROSIS SERVICES, LLC
FQHCLA463A Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Bainbridge
Type
Health Center Program Look-Alike
340B ID
FQHCLA463A
Entity Address
1348 Bainbridge St
Philadelphia, PA 19147-1810
Grant Number
LALCS52965
Participating Start Date
4/1/2024
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
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
5/24/2024
Business decision by covered entity and/or pharmacy
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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