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AZOF ENTERPRISES
STD34952 Midway Specialty Care Center Inc
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Covered Entity Details
Entity Name
Midway Specialty Care Center Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD34952
Entity Address
1801 SE Hillmoor Drive
Ste C207
Port St Lucie, FL 34952
Grant Number
NH25PS005131
Participating Start Date
10/1/2018
Last Recertification Date
5/14/2024
Pharmacy Details
Pharmacy Name
AZOF ENTERPRISES
Pharmacy Address
PORT ST LUCIE DISCOUNT PHARMACY
1936 SE PORT ST LUCIE BLVD
PORT ST LUCIE, FL 34952
Pharmacy Comments
Contract Details
Approval Date
8/20/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Moti Ramgopal, CEO
(772) 464-9746
Contract Pharmacy Representative
AZOF ENTERPRISES
Azubuike Ofokansi, Owner
(772) 446-9284
Signed By Date
7/10/2018
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