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ADDISON'S APOTHECARY INC.
RWII13905 Southern Tier AIDS Program, Inc.
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Covered Entity Details
Entity Name
Southern Tier AIDS Program, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII13905
Entity Address
22 Riverside Drive
Binghamton, NY 13905
Grant Number
X07HA00025
Participating Start Date
7/1/2018
Last Recertification Date
2/3/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
ADDISON'S APOTHECARY INC.
Pharmacy Address
GREEN STREET PHARMACY
131 E GREEN ST STE 2
ITHACA, NY 14850-5661
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Barry, Executive Director
(607) 798-1706 Ext: 113
Contract Pharmacy Representative
Green Street Pharmacy
Nicole Pagano, Co-Owner
(607) 882-9502
Signed By Date
10/16/2017
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