340B Drug Pricing Program Database
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WALGREEN CO.
RWI20825A Amity Medical Group, Inc
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Covered Entity Details
Entity Name
Amity Medical Group, Inc
Subdivision Name
AMG2 Park Rd location
Type
Ryan White Part A
340B ID
RWI20825A
Entity Address
10508 Park Rd Suite 130
Charlotte, NC 28210
Grant Number
H89HA11434
Participating Start Date
7/1/2019
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07401
13720 HIGHWAY 74
INDIAN TRAIL, NC 28079-7600
Pharmacy Comments
Contract Details
Approval Date
6/13/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Olivia Bentley, Dr.
(704) 246-5131
Contract Pharmacy Representative
Walgreens
Andrea Koper, 340B Client Relations
(847) 964-6077
Signed By Date
4/15/2019
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