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870 SOUTHERN DRUG CORP
RWI06114 Latino Community Services, Inc.
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Covered Entity Details
Entity Name
Latino Community Services, Inc.
Subdivision Name
Care & Support
Type
Ryan White Part A
340B ID
RWI06114
Entity Address
28 Grand Street 2nd FL
Hartford, CT 06106
Grant Number
H89HA00044
Participating Start Date
7/1/2017
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
870 SOUTHERN DRUG CORP
Pharmacy Address
D/B/A AVITA PHARMACY 1064
924 MYRTLE AVE
BROOKLYN, NY 11206
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
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