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AVANT PHARMACY AND WELLNESS
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
AVANT PHARMACY AND WELLNESS
Pharmacy Address
2300 RANDOLPH RD UNIT A-2
CHARLOTTE, NC 28207
Pharmacy Comments
Contract Details
Approval Date
9/10/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Olivia Bentley, Dr.
(704) 246-5131
Contract Pharmacy Representative
RX CLINIC PHARMACY
Amina Abubakar, CEO
(704) 537-0909
Signed By Date
9/10/2019
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