Clinical Registrant - Applicant Information
Clinical Registrant - Applicant Information
Clinical Registrant Information
ID Number Name
CR01
Laurel Harvest Labs LLC
Purported ACRC Name Temple University
Source: Clinical Registrant application section 1 & 2
Primary Contact Name Andrew N. Dodge
Primary Contact Phone Primary Contact Email
717-917-8556
Andrew@
Dispensary Business Information
ID Number
Name
Region
Org Type
Address
City
State Zip Code Phone
Fax
CR01-D18-1201 Laurel Harvest 1 ? Southeast Limited Liability 119 South Tree Drive Lancaster PA
Labs LLC
Company
17603
717-917-8556
Source: Dispensary application section 1 & 18
Dispensary Facility Information*
Primary Name
Primary County
Philadelphia
Second Name
Second County Montgomery
Email andrew@
Source: Dispensary application section 2
Dispensary Current Officer(s)
First Name Andrew
Middle Name Nikolaus
Nicholas
Mitchell
Bryan
Glenn
Curtis
Scott
Eric
Tara
Lisa
Therese
Marie
Source: Dispensary application section 20
Last Name Dodge Karalis Baruchowitz Taylor Rosenthal Mulloy Mellet
Suffix R.Ph. Esq.
D.O., P.C.
Occupation Managing Director, Ecore International Chief Executive Officer, Elwyn Pharmacy Group Managing Partner, Merida Capital Partners Member, Board of Governors ? Leafline Labs LLC Physician, Pinnacle Pain Management Chief Operating Officer, GrowWest MD Chief Administrative Officer, Merida Capital Partners
Title in Applicant's business Principal/Financial Backer/Chief Executive Officer Principal/Financial Backer/Head of Dispensary Operations Principal/Financial Backer/Chief Marketing Officer Chief Financial Officer Chief Medical Officer Chief Operating Officer Chief Administrative Officer
* Clinical Registrant applicants could apply for up to six Dispensary facility locations; no Clinical Registrant applicant included more than two locations in their application.
Page 1 of 17
December 5, 2018
Clinical Registrant - Applicant Information
Grower/Processor Business Information
ID Number Name
Region
CR01-
Laurel Harvest Labs LLC 1 ? Southeast
GP18-1201
Source: Grower/Processor application section 1 & 23
Org Type
Limited Liability Company
Address
City
State
119 South Tree Drive Lancaster PA
Zip Code Phone
Fax
17603 717-917-8556
Grower/Processor Facility Information
Name
Address
279 South Barbara Street
City Mount Joy
Zip Code 17552
County Lancaster
Municipality Mount Joy Borough
Email andrew@
Source: Grower/Processor application section 2
Grower/Processor Current Officer(s)
First Name Andrew
Middle Name Last Name
Nikolaus
Dodge
Nicholas
Karalis
Mitchell
Bryan
Baruchowitz
Glenn
Curtis
Taylor
Scott
Eric
Rosenthal
Tara
Lisa
Mulloy
Therese
Marie
Mellet
Source: Grower/Processor application section 25
Suffix R.Ph. Esq.
D.O., P.C.
Occupation Managing Director, Ecore International Chief Executive Officer, Elwyn Pharmacy Group Managing Partner, Merida Capital Partners Member, Board of Governors, Leafline Labs LLC Physician, Pinnacle Pain Management Chief Operating Officer, GrowWest MD Chief Administrative Officer, Merida Capital Partners
Title in Applicant's business Principal/Financial Backer/Chief Executive Officer Principal/Financial Backer/Head of Dispensary Operations Principal/Financial Backer/Chief Marketing Officer Chief Financial Officer Chief Medical Officer Chief Operating Officer Chief Administrative Officer
Page 2 of 17
December 5, 2018
Clinical Registrant - Applicant Information
Clinical Registrant Information
ID Number Name
CR02
Prime Wellness of PA LLC
Source: Clinical Registrant application section 1 & 2
Purported ACRC Name
Drexel University College of Medicine
Primary Contact Name Primary Contact Phone Primary Contact Email
Sharon Ali
847-946-0728
sa@
Grower/Processor Business Information
ID Number Name
Region
CR02-
Prime Wellness of 1 ? Southeast
GP18-1102 Pennsylvania, LLC
Source: Grower/Processor application section 1 & 23
Org Type
Address
Limited Liability 217 Wyoming Avenue Company
City
State Zip Code Phone
Scranton PA 18503 (570) 346-7651
Fax
Email
(570) 344-1542 jadoherty@
Grower/Processor Facility Information
Name Prime Wellness of Pennsylvania, LLC
Address South Heidelberg Industrial Park, 2 Corporate Boulevard
Source: Grower/Processor application section 2
City
Zip Code County Municipality
Sinking Spring 19608
Berks South Heidelberg Township
Grower/Processor Current Officer(s): Not Applicable.
Page 3 of 17
December 5, 2018
Clinical Registrant - Applicant Information
Clinical Registrant Information
ID Number Name
CR03
Cansortium Health Partners, LLC
Source: Clinical Registrant application section 1 & 2
Purported ACRC Name
Primary Contact Name
Philadelphia Center for Osteopathic Samantha Hymes, CEO Medicine
Primary Contact Phone Primary Contact Email
813-477-9546
sam@
Dispensary Business Information
ID Number
Name
CR03-D18-1802 Cansortium Health Partners, LLC
Source: Dispensary application section 1 & 18
Region 1 ? Southeast
Org Type
Limited Liability Company
Address
City
State Zip Code
1150 First Avenue, Suite 511 King of Prussia PA 19406
Phone
Fax
813-477-9546
Dispensary Facility Information*
Primary Name
Primary County
Cansortium Health Partners. LLC Philadelphia
Email sam@
Source: Dispensary application section 2
Dispensary Current Officer(s)
First Name
Middle Name
SAMANTHA
ALBERTO
MARCOS
MICHELLE
Source: Dispensary application section 20
Last Name HYMES FARINEZ PEDREIRA ROTH
Suffix
Occupation CHIEF EXECUTIVE OFFICER CHIEF OPERATING OFFICER CHIEF FINANCIAL OFFICER FINANCIAL BACKER
Title in Applicant's business CEO COO CFO FINANCIAL BACKER
* Clinical Registrant applicants could apply for up to six Dispensary facility locations; no Clinical Registrant applicant included more than two locations in their application.
Page 4 of 17
December 5, 2018
Clinical Registrant - Applicant Information
Grower/Processor Business Information
ID Number Name
Region
CR03-GP18- Cansortium Health 3 ? Southcentral
3801
Partners, LLC
Source: Grower/Processor application 1 & 23
Org Type
Limited Liability Company
Address
City
State Zip Code
1150 First Avenue, King of Prussia PA Suite 511
19406
Phone
Fax
813-477-9546
Grower/Processor Facility Information
Name
Address
Cansortium Health Partners, LLC
433 Fikes School Road
City
Zip Code
York Springs 17372
County Adams
Municipality Huntington
Email sam@
Source: Grower/Processor application section 2
Grower/Processor Current Officer(s)
First Name
Middle Name Last Name
SAMANTHA
HYMES
ALBERTO
FARINEZ
MARCOS
PEDREIRA
MICHELLE
Source: Grower/Processor application section 25
ROTH
Suffix
Occupation CHIEF EXECUTIVE OFFICER CHIEF OPERATING OFFICER CHIEF FINANCIAL OFFICER FINANCIAL BACKER
Title in Applicant's business CEO COO CFO FINANCIAL BACKER
Page 5 of 17
December 5, 2018
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