Contract Pharmacy Details

WALGREEN CO.
RWIID303031 GEORGIA DEPT OF PUBLIC HEALTH

Covered Entity Details

Entity Name

GEORGIA DEPT OF PUBLIC HEALTH

Subdivision Name

Type

Ryan White Part B ADAP Direct Purchase

340B ID

RWIID303031

Entity Address

200 Piedmont Ave. SE
West Tower
Suite 1508
ATLANTA, GA 30334

Grant Number

X07HA22709

Participating Start Date

4/1/1997

Last Recertification Date

2/11/2025

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #13873
2675 N DECATUR ROAD STE 101
DECATUR, GA 30033

Pharmacy Comments

Contract Details

Approval Date

4/13/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Marisol Cruz, HIV Care Program Manager
(404) 463-2453

Contract Pharmacy Representative

Walgreens #13873
Olivia Ward, Pharmacist
(404) 299-5411

Signed By Date

4/13/2020

340B Drug Pricing Program Database