Covered Entity Details

RWI20825C Amity Medical Group, Inc (Active) - information as of 4/27/2025 10:49:34 PM

Main Details

Name

Amity Medical Group, Inc

Subdivision Name

AMG4 Dallas location

Type

Ryan White Part A

340B ID

RWI20825C

Grant Number

H89HA11434

Additional Details

Current Program Status

Active

Registration Date

6/7/2022

Participating Start Date

6/9/2022

Participating Approval Date

6/9/2022

Last Recertification Date

2/13/2025

Time Period the Assistance was Received

3/1/2023 - 2/28/2026

Contacts

Authorizing Official

Amity Medical Group, Inc
Olivia Bentley, Executive Director
(704) 968-8353

Primary Contact

Amity Medical Group
Amy Kern, Director of Pharmacy
(704) 575-6350

Addresses

Street Address

824 Lower Dallas Hwy
Dallas, NC 28034

Billing Address

Amity Medical Group, Inc
6010 East W.T. Harris Blvd
A
Charlotte, NC 28215

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
NC		1760719348,1003301300,1760491823,1427186022,1306137526,1366429094,1356365480

Shipping Addresses

Shipping Address 1

Amity Medical Group, Inc
824 Lower Dallas Hwy
Dallas, NC 28034

Shipping Address 2

Amity Medical Group, Inc
6010 East W.T. Harris Blvd
Ste A
Charlotte, NC 28215

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/10/2024	04/01/2024		04/01/2024
Contract Detail	AFYA GROUP, LLC	DBA AVANT PHARMACY AND WELLNESS	9835 MONROE RD	CHARLOTTE	NC	28270	07/15/2022	08/29/2022		08/29/2022
Contract Detail	AVANT PHARMACY AND WELLNESS	6010 E WT HARRIS BLVD		CHARLOTTE	NC	28215-4084	07/15/2022	08/29/2022		08/29/2022
Contract Detail	AVANT PHARMACY AND WELLNESS	2300 RANDOLPH RD UNIT A-2		CHARLOTTE	NC	28207	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	01/14/2023	04/01/2023		04/01/2023
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	01/14/2023	04/01/2023		04/01/2023
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/15/2022	08/29/2022		08/29/2022
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/15/2022	08/29/2022		08/29/2022
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/15/2022	08/29/2022		08/29/2022
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/15/2022	08/29/2022		08/29/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/15/2022	08/29/2022		08/29/2022
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/15/2022	08/29/2022		08/29/2022
Contract Detail	FOUNTAIN PLAZA PHARMACY DBA FOUNTAINRX	2825 W. ANDREW JOHNSON HWY.		MORRISTOWN	TN	37814	07/15/2022	08/29/2022		08/29/2022
Contract Detail	GEORGIA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06369	5690 OGEECHEE RD.	SAVANNAH	GA	31405	07/14/2023	10/01/2023		10/01/2023
Contract Detail	HOLIDAY CVS, L.L.C.	DBA: CVS/PHARMACY # 03126	1220 S TAMIAMI TRAIL	OSPREY	FL	34229	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS/PHARMACY #10574	4908 HOUSTON FIELD COURT	CHARLOTTE	NC	28277	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17168	9841 NORTHLAKE CENTRE PKWY	CHARLOTTE	NC	28216	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 16916	8830 ALBEMARLE RD	CHARLOTTE	NC	28227	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 16235	9531 SOUTH BLVD	CHARLOTTE	NC	28273	07/15/2022	10/01/2022		10/01/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17215	12830 WALKER BRANCH RD	CHARLOTTE	NC	28273	07/15/2022	10/01/2022		10/01/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17178	9870 REA RD	CHARLOTTE	NC	28277	07/15/2022	10/01/2022		10/01/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06518	11430 N TRYON ST	CHARLOTTE	NC	28262	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02559	10515 MALLARD CREEK ROAD	CHARLOTTE	NC	28262	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05264	6428 REA ROAD	CHARLOTTE	NC	28277	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07090	16035 JOHNSTON RD.	CHARLOTTE	NC	28277	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04022	210 E. TRADE ST., STE. E-186	CHARLOTTE	NC	28202	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07089	231 N. GRAHAM STREET	CHARLOTTE	NC	28202	07/15/2022	10/01/2022		10/01/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05583	2939 THE PLAZA	CHARLOTTE	NC	28205	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02560	2035 NORTH SHARON AMITY RD	CHARLOTTE	NC	28205	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07688	3440 WILKINSON BOULEVARD	CHARLOTTE	NC	28208	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03319	9915 PARK CEDAR DR	CHARLOTTE	NC	28210	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03526	306 EAST WOODLAWN RD	CHARLOTTE	NC	28217	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02561	4100 CARMEL ROAD	CHARLOTTE	NC	28226	07/15/2022	10/01/2022		10/01/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07056	2115 BEATTIES FORD RD	CHARLOTTE	NC	28216	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05463	9805 ROCKY RIVER RD.	CHARLOTTE	NC	28215	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03694	2325 VILLAGE LAKE DR.	CHARLOTTE	NC	28212	07/15/2022	08/29/2022	12/12/2023	01/16/2024
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07407	6110 THE PLAZA	CHARLOTTE	NC	28215	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08260	8220 MOUNT HOLLY HUNTERSVILLE RD.	CHARLOTTE	NC	28216	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07941	8420 STEELE CREEK RD.	CHARLOTTE	NC	28273	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02562	115 W. ARROWOOD RD.	CHARLOTTE	NC	28217	07/15/2022	08/29/2022		08/29/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02233	6750 WILKINSON BLVD.	BELMONT	NC	28012	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03823	1850 WEST FRANKLIN BOULEVARD	GASTONIA	NC	28052	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03837	1803 S. NEW HOPE ROAD	GASTONIA	NC	28054	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04490	2580 COURT DRIVE	GASTONIA	NC	28054	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06406	3126 DALLAS-HIGH SHOALS HWY.	DALLAS	NC	28034	09/08/2022	09/08/2022	11/06/2023	01/16/2024
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07578	3658 SOUTH NEW HOPE RD.	GASTONIA	NC	28056	09/08/2022	09/08/2022		09/08/2022
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02326	5700 ALBEMARLE ROAD	CHARLOTTE	NC	28212	01/14/2023	04/01/2023		04/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 00187	14125 STEELE CREEK RD.	CHARLOTTE	NC	28273	04/15/2023	07/01/2023		07/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01737	6300 MONROE WEDDINGTON RD.	MATTHEWS	NC	28104	04/15/2023	07/01/2023		07/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02571	1235 PECAN AVE.,	CHARLOTTE	NC	28205	04/15/2023	07/01/2023		07/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 02749	5225 POPLAR TENT RD	CONCORD	NC	28027	04/15/2023	07/01/2023		07/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03852	3000 BATTLEGROUND AVE.	GREENSBORO	NC	27408	04/15/2023	07/01/2023		07/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05445	5100 BEATTIES FORD RD.	CHARLOTTE	NC	28216	07/14/2023	10/01/2023		10/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07157	13845 CONLAN CIRCLE	CHARLOTTE	NC	28277	07/14/2023	10/01/2023		10/01/2023
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03514	442 HIGHWAY 27 SOUTH	STANLEY	NC	28164	01/10/2024	04/01/2024		04/01/2024
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03540	4391 CENTRAL AVE.	CHARLOTTE	NC	28205	01/10/2024	04/01/2024		04/01/2024
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04299	1305 MATTHEWS TOWNSHIP PKWY	MATTHEWS	NC	28105	01/10/2024	04/01/2024		04/01/2024
Contract Detail	NORTH CAROLINA CVS PHARMACY, L.L.C.	CVS PHARMACY # 17319	900 METROPOLITAN AVE STE 2	CHARLOTTE	NC	28204	01/10/2024	04/01/2024		04/01/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/15/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/15/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/15/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	07/15/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/15/2022	08/29/2022		08/29/2022
Contract Detail	PROCARE PHARMACY, LLC	DBA CVS/PHARMACY#2980	601 S. KINGS DR.	CHARLOTTE	NC	28204	07/15/2022	08/29/2022		08/29/2022
Contract Detail	RXCP4 INC DBA AVANT PHARMACY AND WELLNES	824 LOWER DALLAS HWY		DALLAS	NC	28034	01/14/2023	04/01/2023		04/01/2023
Contract Detail	SOUTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 04288	2707 CELANESE RD.	ROCK HILL	SC	29732	04/15/2023	07/01/2023		07/01/2023
Contract Detail	SOUTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07005	333 HWY 9 BYPASS	LANCASTER	SC	29720	01/10/2024	04/01/2024		04/01/2024
Contract Detail	SOUTH CAROLINA CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 07556	2401 SUNSET BOULEVARD	WEST COLUMBIA	SC	29169	01/10/2024	04/01/2024		04/01/2024
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	01/14/2023	04/01/2023		04/01/2023
Contract Detail	WAL-MART PHARMACY 10-2134	7735 NORTH TRYON ST		CHARLOTTE	NC	28262	01/09/2024	04/01/2024		04/01/2024
Contract Detail	WAL-MART PHARMACY WHSE #45	2250 NORTH 8TH STREET	SUITE 102-A	ROGERS	AR	72756	01/14/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15008	101 S TRYON ST STE 22	CHARLOTTE	NC	28280	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10838	5220 HIGHWAY 557	CLOVER	SC	29710	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS #15392	4625 HYLAS LANE	HUNTERSVILLE	NC	28078	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16405	1500 E 3RD ST STE A	CHARLOTTE	NC	28204	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA WALGREENS #16087	9428 STEELE CREEK RD.	CHARLOTTE	NC	28273	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	COMMUNITY, A WALGREENS PHARMACY #16420	103 COMMERCE CENTRE DR. SUITE 101	HUNTERSVILLE	NC	28078	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15274	1645 CRANIUM DRIVE	ROCK HILL	SC	29732	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04870	735 CABARRUS AVE W	CONCORD	NC	28027	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07699	1495 CONCORD PKWY N	CONCORD	NC	28025-0818	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11424	9432 MT. HOLLY HUNTERSVILLE RD.	HUNTERSVILLE	NC	28078	07/15/2022	10/01/2022	07/27/2022	07/27/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10287	9848 GILEAD RD.	HUNTERSVILLE	NC	28078	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #13985	7828 PINEVILLE MATTHEWS RD.	CHARLOTTE	NC	28226-4033	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #18350	2907 HIGHWAY160 W	FORT MILL	SC	29708	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #17234	21500 CATAWBA AVE	CORNELIUS	NC	28031-6577	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #19943	2465 S NEW HOPE RD	GASTONIA	NC	28054	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #17368	617 HIGHLAND ST	MOUNT HOLLY	NC	28120	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #17250	1728 SOUTH BLVD	CHARLOTTE	NC	28203	07/15/2022	10/01/2022	07/27/2022	07/27/2022
Contract Detail	WALGREEN CO.	WALGREENS #17014	3534 MT HOLLY-HUNTERSVILLE RD	CHARLOTTE	NC	28216	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #17386	3716 W W T HARRIS BLVD STE J	CHARLOTTE	NC	28269-8517	07/15/2022	08/29/2022	04/29/2025	04/04/2025
Contract Detail	WALGREEN CO.	WALGREENS #17660	12830 SOUTH TRYON ST	CHARLOTTE	NC	28273	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #19877	10020 PINEVILLE MATTHEWS RD	PINEVILLE	NC	28134	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #19654	544 PROVIDENCE RD	CHARLOTTE	NC	28207	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #17073	4133 PARK RD	CHARLOTTE	NC	28209	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #18053	6231 FAIRVIEW RD	CHARLOTTE	NC	28210	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #19702	8520 PARK RD	CHARLOTTE	NC	28210	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #18352	334 S SHARON AMITY RD	CHARLOTTE	NC	28211	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #19220	3345 PINEVILLE-MATTHEWS RD	CHARLOTTE	NC	28226	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #19646	7115 E W. T. HARRIS BLVD	CHARLOTTE	NC	28227	07/15/2022	08/29/2022	04/22/2025	04/22/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11396	2200 W. SUGAR CREEK RD.	CHARLOTTE	NC	28262	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11692	500 FINCHER ST.	MONROE	NC	28112	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04546	3080 MILTON RD.	CHARLOTTE	NC	28215	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04547	8538 N TRYON ST	CHARLOTTE	NC	28262	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04843	6802 W WILKINSON BLVD	BELMONT	NC	28012	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04869	3251 FREEDOM DR.	CHARLOTTE	NC	28208	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05877	1902 WEST FRANKLIN BLVD.	GASTONIA	NC	28052	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07859	2975 UNION ROAD	GASTONIA	NC	28054-6023	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	WALGREENS #10608	1000 DALLAS CHERRYVILLE HWY.	DALLAS	NC	28034	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01376	6649 CARNEGIE BLVD	CHARLOTTE	NC	28211	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04871	1310 S CANNON BLVD	KANNAPOLIS	NC	28083	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05761	4701 SOUTH BLVD	CHARLOTTE	NC	28217	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06480	2800 W MALLARD CREEK CHURCH RD	CHARLOTTE	NC	28262	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07401	13720 HIGHWAY 74	INDIAN TRAIL	NC	28079-7600	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10275	5040 BEATTIES FORD RD.	CHARLOTTE	NC	28216-2835	07/15/2022	10/01/2022		10/01/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11266	19631 W. CATAWBA AVE.	CORNELIUS	NC	28031	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10255	5975 WEDDINGTON MONROE RD.	MATTHEWS	NC	28104	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11251	2531 CUTHBERTSON RD.	WAXHAW	NC	28173	07/15/2022	08/29/2022	04/01/2024	04/08/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS #09184	11200 PROVIDENCE RD. WEST	CHARLOTTE	NC	28277	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11210	2000 CELANESE RD.	ROCK HILL	SC	29732	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04548	6848 ALBEMARLE RD.	CHARLOTTE	NC	28212	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06479	1220 MATTHEWS TOWNSHIP PKWY	MATTHEWS	NC	28105-0218	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07342	7711 COLONY ROAD	CHARLOTTE	NC	28226	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07766	1510 SARDIS RD N	CHARLOTTE	NC	28270-1408	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09084	3431 MATTHEWS-MINT HILL RD	MATTHEWS	NC	28105-4030	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12350	5455 POTTER RD.	STALLINGS	NC	28104	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREEN CO.	WALGREENS #21284	200 HAWTHORNE LN STE T1578	CHARLOTTE	NC	28204	10/04/2022	01/01/2023		01/01/2023
Contract Detail	WALGREENS OF NORTH CAROLINA INC.	COMMUNITY, A WALGREENS PHARMACY #16313	2816 ERWIN ROAD SUITE 105	DURHAM	NC	27705	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/15/2022	08/29/2022		08/29/2022
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/15/2022	10/01/2022	07/15/2022	07/15/2022
Contract Detail	WALMART PHARMACY 10-4148	8800 EAST WT HARRIS BLVD		CHARLOTTE	NC	28227	01/09/2024	04/01/2024		04/01/2024
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	10/15/2023	01/01/2024	04/01/2024	04/08/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Richardson, Zach COO Amity Medical Group 2527647967	Kern, Amy Director of Pharmacy Amity Medical Group 7045756350	3/25/2025 8:43 AM
Details	Last Recertification Date	Update	Recertification	1/30/2024 10:28:39 PM	2/13/2025 10:48:57 PM	2/13/2025 10:48 PM
Details	Assistance Received To Date	Update	Change Request	2/28/2024 12:00:00 AM	2/28/2026 12:00:00 AM	7/1/2024 12:02 PM
Details	Last Recertification Date	Update	Recertification	1/30/2023 10:46:36 AM	1/30/2024 10:28:39 PM	1/30/2024 10:28 PM
Contacts	Primary Contact	Update	Change Request	Acevedo, Nestor Programs Manager Amity Medical Group, Inc 7042465131	Richardson, Zach COO Amity Medical Group 2527647967	1/4/2024 10:24 AM
Details	Assistance Received From Date	Update	Change Request	3/1/2022 12:00:00 AM	3/1/2023 12:00:00 AM	1/4/2024 10:24 AM
Details	Assistance Received To Date	Update	Change Request	2/28/2023 12:00:00 AM	2/28/2024 12:00:00 AM	1/4/2024 10:24 AM
Details	NOFO Number	Update		HRSA-22-018		12/16/2023 10:34 AM
Details	Last Recertification Date	Update	Recertification		1/30/2023 10:46:36 AM	1/30/2023 10:46 AM
Addresses	Shipping Address	Insert	Change Request		Amity Medical Group, Inc 824 Lower Dallas Hwy Dallas, NC 28034	1/25/2023 7:01 AM
Addresses	Shipping Address	Insert	Change Request		Amity Medical Group, Inc 6010 East W.T. Harris Blvd Ste A Charlotte, NC 28215	1/25/2023 7:01 AM
Details	State	Update	OPA Edit	Approved	Active	6/9/2022 7:01 AM
Dates	Start Date	Update	OPA Edit	7/1/2022 12:00:00 AM	6/9/2022 12:00:00 AM	6/9/2022 7:01 AM
Contacts	Signed By	Insert	New Registration		Bentley, Olivia Executive Director Amity Medical Group, Inc 7049688353	6/9/2022 6:52 AM
Details	340B ID	Update	New Registration		RWI20825C	6/9/2022 6:52 AM
Dates	Participating Approval Date	Update	New Registration		6/9/2022 6:52:38 AM	6/9/2022 6:52 AM
Details	State	Update	New Registration	Pending	Approved	6/9/2022 6:52 AM
Dates	Signed By Date	Update	New Registration		6/7/2022 9:46:27 AM	6/9/2022 6:52 AM
Dates	Start Date	Update	New Registration		7/1/2022 12:00:00 AM	6/9/2022 6:52 AM
Addresses	Main Address	Insert	New Registration		824 Lower Dallas Hwy Dallas, NC 28034	6/7/2022 9:46 AM
Addresses	Billing Address	Insert	New Registration		Amity Medical Group, Inc 6010 East W.T. Harris Blvd A Charlotte, NC 28215	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760719348	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1003301300	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1760491823	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1427186022	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1306137526	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1366429094	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1356365480	6/7/2022 9:46 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	6/7/2022 9:46 AM
Contacts	Primary Contact	Insert	New Registration		Acevedo, Nestor Programs Manager Amity Medical Group, Inc 7042465131	6/7/2022 9:46 AM
Contacts	Authorizing Official	Insert	New Registration		Bentley, Olivia Executive Director Amity Medical Group, Inc 7049688353	6/7/2022 9:46 AM
Details	Assistance Received From Date	Insert	New Registration		3/1/2022 12:00:00 AM	6/7/2022 9:46 AM
Details	Assistance Received To Date	Insert	New Registration		2/28/2023 12:00:00 AM	6/7/2022 9:46 AM
Details	Last Recertification Date	Insert	New Registration			6/7/2022 9:46 AM
Details	Grant Number	Insert	New Registration		H89HA11434	6/7/2022 9:46 AM
Details	340B ID	Insert	New Registration			6/7/2022 9:46 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			6/7/2022 9:46 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			6/7/2022 9:46 AM
Details	Medicare Provider Number	Insert	New Registration			6/7/2022 9:46 AM
Details	Entity Name	Insert	New Registration		Amity Medical Group, Inc	6/7/2022 9:46 AM
Details	NOFO Number	Insert	New Registration		HRSA-22-018	6/7/2022 9:46 AM
Details	Program Code	Insert	New Registration		RWI	6/7/2022 9:46 AM
Details	Entity Subname	Insert	New Registration		AMG4 Dallas location	6/7/2022 9:46 AM
Dates	Participating Approval Date	Insert	New Registration			6/7/2022 9:46 AM
Details	State	Insert	New Registration		Pending	6/7/2022 9:46 AM
Dates	Registration Date	Insert	New Registration		6/7/2022 9:46:23 AM	6/7/2022 9:46 AM
Dates	Signed By Date	Insert	New Registration			6/7/2022 9:46 AM
Dates	Start Date	Insert	New Registration			6/7/2022 9:46 AM
Terminations	Termination Comments	Insert	New Registration			6/7/2022 9:46 AM
Terminations	Termination Date	Insert	New Registration			6/7/2022 9:46 AM
Terminations	Termination Effective Date	Insert	New Registration			6/7/2022 9:46 AM
Terminations	Termination Reason	Insert	New Registration			6/7/2022 9:46 AM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History