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WALGREEN EASTERN CO., INC.
RW424852 Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Mazzoni Annex
Type
Ryan White Part D
340B ID
RW424852
Entity Address
253 South 10th Street
Philadelphia, PA 19107
Grant Number
H12HA24852
Participating Start Date
10/1/2016
Last Recertification Date
1/27/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS #11780
2655 SOUTH TENTH ST.
PHILADELPHIA, PA 19148
Pharmacy Comments
Contract Details
Approval Date
7/22/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Walgreen Eastern Co., Inc
Lindsey Karle, 340B Client Analyst
(847) 964-8159
Signed By Date
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