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GREAT LAKES PHARMACY
RWI44102 Nueva Luz Urban Resource Center
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Covered Entity Details
Entity Name
Nueva Luz Urban Resource Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI44102
Entity Address
6600 Detroit Avenue
Cleveland, OH 44102
Grant Number
H89HA23812
Participating Start Date
7/1/2016
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
GREAT LAKES PHARMACY
Pharmacy Address
9500 MENTOR AVE STE 110
MENTOR, OH 44060-8712
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/12/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Max Rodas, Chief Executive Officer
(216) 857-0558
Contract Pharmacy Representative
Nota Consulting Group, LLC
Fungisai Nota, 340B Program Manager
(610) 742-7763
Signed By Date
4/16/2018
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