340B Drug Pricing Program Database
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Begin Date
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November 2024
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Carve-In Date
November 2024
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 Covered Entity Details
340B ID
Participating
Approved
Entity Name
Entity Sub-Division Name
 Covered Entity Address
Address 1
Address 2
Address 3
City
State
Zip
Second Zip
 Contract CE Signed By Information
Signed By Name
Signed By Title
Signed By Telephone
Signed By Extension
 Contract Pharmacy Rep Information
Contract Pharmacy Rep Name
Contract Pharmacy Rep Title
Contract Pharmacy Rep Telephone
Contract Pharmacy Rep Extension
 Pharmacy Details
Pharmacy Name
Pharmacy Comments
Pharmacy ID
 Pharmacy Address
Address 1
Address 2
Address 3
City
State
Zip
Second Zip
 Contract Pharmacy Signed By Information
Signed By Name
Signed By Title
Signed By Telephone
Signed By Extension
 Contract Information
Contract Begin Date
Contract Approval Date
Contract Term Date
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