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PRAXIS SPECIALTY PHARMACY LLC
CH05972AJ AUNT MARTHA'S YOUTH SERVICE CENTER, INC.
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Covered Entity Details
Entity Name
AUNT MARTHA'S YOUTH SERVICE CENTER, INC.
Subdivision Name
Roseland Community Health Center
Type
HRSA-Funded Health Center
340B ID
CH05972AJ
Entity Address
45 W. 111th Street
3rd Floor West
Chicago, IL 60628
Grant Number
H80CS00685
Participating Start Date
7/1/2014
Last Recertification Date
3/7/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
PRAXIS SPECIALTY PHARMACY LLC
Pharmacy Address
PRAXIS RX PHARMACY
5455 W WATERS AVE STE 214
TAMPA, FL 33634
Pharmacy Comments
Contract Details
Approval Date
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Audrey Pennington, Chief Operating Officer
(708) 747-7100
Contract Pharmacy Representative
William Scott Bailey, Pharmacist in Charge
(888) 903-7453
Signed By Date
4/14/2017
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