Contract Pharmacy Details

GOLD'S PHARMACY
RW424852A Mazzoni Center

Covered Entity Details

Entity Name

Mazzoni Center

Subdivision Name

Type

Ryan White Part D

340B ID

RW424852A

Entity Address

1348 Bainbridge Street
Philadelphia, PA 19147-1810

Grant Number

H12HA24852

Participating Start Date

10/1/2016

Last Recertification Date

2/16/2020

Entity Termination Date

4/1/2021

Pharmacy Details

Pharmacy Name

GOLD'S PHARMACY

Pharmacy Address

7543 HAVERFORD AVE
PHILADELPHIA, PA 19151-2226

Pharmacy Comments

Contract Details

Approval Date

4/3/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/16/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Ronald Powers, COO
(215) 563-0652 Ext: 210

Contract Pharmacy Representative

Gold's Pharmacy
Evan Lessa, CEO
(215) 879-4653

Signed By Date

4/3/2018