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WALGREEN CO
RWIID303031 GEORGIA DEPT OF PUBLIC HEALTH
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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 # 05759
585 DEKALB INDUSTRIAL WAY
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
Shauna Markes-Wilson, PIC
(770) 547-6508
Signed By Date
4/13/2020
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