Contract Pharmacy Details

MAXI DRUG SOUTH, LP
CH010580 PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE

Covered Entity Details

Entity Name

PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE

Subdivision Name

PROVIDENCE COMMUNITY HEALTH CENTERS, INC.

Type

HRSA-Funded Health Center

340B ID

CH010580

Entity Address

375 Allens Ave
Providence, RI 02905-5010

Grant Number

H80CS00057

Participating Start Date

7/1/1996

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

MAXI DRUG SOUTH, LP

Pharmacy Address

RITE AID #10253
200 ACADEMY AVENUE
PROVIDENCE, RI 02908

Pharmacy Comments

Contract Details

Approval Date

7/13/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/11/2018
Ownership change

Contacts

Covered Entity Signing Official

MERRILL THOMAS, CEO
(401) 444-0400 Ext: 3130

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

7/13/2017

340B Drug Pricing Program Database