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BROTHER'S PHARMACY
STD704331 Baldone Reina Dermatology
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Covered Entity Details
Entity Name
Baldone Reina Dermatology
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD704331
Entity Address
150Lakeview Circle
Covington, LA 70433
Grant Number
NH25PS005176
Participating Start Date
10/1/2024
Last Recertification Date
5/9/2025
Pharmacy Details
Pharmacy Name
BROTHER'S PHARMACY
Pharmacy Address
BROTHER'S PHARMACY LLC
6200 LESLIE LN
LAKE CHARLES, LA 70615
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
10/17/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephanie C Moga, Office Manager
(985) 892-3376
Contract Pharmacy Representative
Pharmacy
Troy Tate, President
(800) 291-1089
Signed By Date
10/15/2024
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