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CUSTOM RX, INC
CHC26631-00 LA CASA DE SALUD INC.
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Covered Entity Details
Entity Name
LA CASA DE SALUD INC.
Subdivision Name
La Casa de Salud, Inc.
Type
HRSA-Funded Health Center
340B ID
CHC26631-00
Entity Address
966 Prospect Ave
Bronx, NY 10459-3270
Grant Number
H80CS26631
Participating Start Date
7/1/2014
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
CUSTOM RX, INC
Pharmacy Address
90-09 37TH AVE
JACKSON HEIGHTS, NY 11372
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
4/15/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Pamela Mattel, CEO
(718) 960-7601
Contract Pharmacy Representative
Custom Rx Inc.
German Jamie, President
(347) 591-4470
Signed By Date
10/16/2017
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