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WALGREENS SPECIALTY PHARMACY, LLC
RW424852A Mazzoni Center
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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
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
4/9/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/22/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ronald Powers, COO
(215) 563-0652 Ext: 210
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/9/2018
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