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IC PHARMACY LLC
CH092880 Lifelong Medical Care
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Covered Entity Details
Entity Name
Lifelong Medical Care
Subdivision Name
LIFELONG MEDICAL CARE
Type
HRSA-Funded Health Center
340B ID
CH092880
Entity Address
2344 6th St
Berkeley, CA 94710-2412
Grant Number
H80CS00808
Participating Start Date
9/9/2005
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
IC PHARMACY LLC
Pharmacy Address
AMAZON PHARMACY #004
34 35TH STREET
STE 4BSW, UNIT 28
BROOKLYN, NY 11232
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Vliet, CEO
(510) 981-4123
Contract Pharmacy Representative
PillPack by Amazon Pharmacy
John Lavin, Vice President
(714) 380-0579
Signed By Date
1/16/2024
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