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1101A NORTH JEFFERSON PHARMACY LLC
STD64106 BlaqOut, Inc.
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Covered Entity Details
Entity Name
BlaqOut, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD64106
Entity Address
517 Campbell Street
Kansas City, MO 64106
Grant Number
NH25PS005142
Participating Start Date
4/1/2020
Last Recertification Date
5/13/2024
Pharmacy Details
Pharmacy Name
1101A NORTH JEFFERSON PHARMACY LLC
Pharmacy Address
DBA BOCA PHARMACY
1101A N JEFFERSON AVE
SAINT LOUIS, MO 63106
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
D. Rashaan Gilmore, President/CEO
(816) 866-0355
Contract Pharmacy Representative
866 EAST TREMONT PHARMACY LLC
Jacob Jamron, CEO
(718) 344-7853
Signed By Date
7/15/2024
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