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JACKSON DRUGS, LLC
RWII34982B Midway Specialty Care Center Inc
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Covered Entity Details
Entity Name
Midway Specialty Care Center Inc
Subdivision Name
Type
Ryan White Part B
340B ID
RWII34982B
Entity Address
1801 SE Hillmoor Drive
C207
Port St Lucie, FL 34952
Grant Number
X07HA00057
Participating Start Date
10/1/2018
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
JACKSON DRUGS, LLC
Pharmacy Address
2301 OKEECHOBEE RD
FORT PIERCE, FL 34950-6554
Pharmacy Comments
Contract Details
Approval Date
8/22/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Moti Ramgopal, CEO
(772) 464-9746
Contract Pharmacy Representative
Jackson Drugs
Ken Jackson, Owner
(772) 201-2756
Signed By Date
7/10/2018
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