Contract Pharmacy Details

JACKSON DRUGS, LLC
STD349721 Midway Specialty Care Center Inc

Covered Entity Details

Entity Name

Midway Specialty Care Center Inc

Subdivision Name

Type

Sexually Transmitted Diseases

340B ID

STD349721

Entity Address

113 NE 19TH DRIVE
OKEECHOBEE, FL 34972

Grant Number

NH25PS005131

Participating Start Date

10/1/2018

Last Recertification Date

5/12/2020

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

8/20/2018

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