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KTJ ENTERPRISES 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
KTJ ENTERPRISES LLC
Pharmacy Address
PRESCRIPTION SHOP OF STUART
622 COLORADO AVE
D B A PRESCRIPTION SHOP STUART
STUART, FL 34994-3016
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kathryn E Hayden, CFO
(772) 742-9276
Contract Pharmacy Representative
KTJ Enterprises LLC
Kim Jones, Owner
(772) 287-3443
Signed By Date
10/10/2019
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