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RELIANT MEDICAL LLC DBA RELIANT HEALTHCA
STD71104 The Philadelphia Center
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Covered Entity Details
Entity Name
The Philadelphia Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD71104
Entity Address
2020 Centenary Blvd.
Shreveport, LA 71104
Grant Number
NH25PS005176
Participating Start Date
1/1/2014
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
RELIANT MEDICAL LLC DBA RELIANT HEALTHCA
Pharmacy Address
1004 N 19TH ST
MONROE, LA 71201-5734
Pharmacy Comments
11/15/10 UPDATED ADDR (WAS 300 N. STANLEY);
Contract Details
Approval Date
4/12/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Alan Miciotto, Executive Director
(318) 222-6633 Ext: 2012
Contract Pharmacy Representative
Reliant Healthcare
BRAD SMITH, CEO
(318) 322-8326
Signed By Date
4/12/2017
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