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AZOF ENTERPRISES
RWII34982A 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
RWII34982A
Entity Address
113 NE 19TH DRIVE
OKEECHOBEE, FL 34972
Grant Number
X07HA00057
Participating Start Date
10/1/2018
Last Recertification Date
1/28/2020
Entity Termination Date
1/1/2021
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
8/22/2018
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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