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PENNSYLVANIA CVS PHARMACY, L.L.C.
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
PENNSYLVANIA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04007
3925 WALNUT ST.
PHILADELPHIA, PA 19104
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alecia Manley, Executive Operating Officer
(215) 563-0652
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/11/2024
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