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PHYSICIAN'S RX PHARMACY, LLC
STD84109 Hope on T.T.a.P.P.
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Covered Entity Details
Entity Name
Hope on T.T.a.P.P.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD84109
Entity Address
2468 E EVERGREEN AVE
Salt Lake City, UT 84109-3008
Grant Number
5 NU51PS005170-03-00
Participating Start Date
4/1/2023
Last Recertification Date
5/9/2024
Pharmacy Details
Pharmacy Name
PHYSICIAN'S RX PHARMACY, LLC
Pharmacy Address
PHYSICIANS RX PHARMACY, LLC
9701 APOLLO DRIVE
#400
LARGO, MD 20774
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
Sequan Kolibas, Executive Director
(801) 808-4260
Contract Pharmacy Representative
Physicians Rx Pharmacy of Clinton
Chris Wakefield, Manager
(412) 357-5163
Signed By Date
1/16/2024
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