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JACKSON DRUGS, LLC
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
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
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
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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