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870 SOUTHERN DRUG CORP
STD061141 Latino Community Services, Inc.
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Covered Entity Details
Entity Name
Latino Community Services, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD061141
Entity Address
28 Grand Street 2nd FL
Hartford, CT 06106
Grant Number
1NH25PS005155 01
Participating Start Date
7/1/2017
Last Recertification Date
5/6/2024
Entity Termination Date
7/1/2025
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
4/24/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
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