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JAC PHARMACY INC
FQHCLA306 APICHA Community Health Center
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Covered Entity Details
Entity Name
APICHA Community Health Center
Subdivision Name
Type
Health Center Program Look-Alike
340B ID
FQHCLA306
Entity Address
400 Broadway
New York, NY 10013
Grant Number
LALCS00137
Participating Start Date
10/27/2012
Last Recertification Date
2/11/2015
Entity Termination Date
1/1/2016
Pharmacy Details
Pharmacy Name
JAC PHARMACY INC
Pharmacy Address
.
93-15 ROOSEVELT AVE
JACKSON HEIGHTS, NY 11372
Pharmacy Comments
Contract Details
Approval Date
1/25/2013
Contract Begin Date
1/25/2013
Carve-In Effective Date
Contract Comments
01/25/2013 - public health emergency declared in the state of NY effective 10/27/2012
Contract Termination Date
Termination Reason
1/1/2016
Contacts
Covered Entity Signing Official
Teresita R. Rodriguez, CEO
(212) 334-7940 Ext: 5377
Contract Pharmacy Representative
National Rx Pharma
Jose Campon, President
(516) 523-6948
Signed By Date
12/13/2012
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