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WALMART PHARMACY 10-2946
STD333052 Independent Medical Group, LLC
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Covered Entity Details
Entity Name
Independent Medical Group, LLC
Subdivision Name
Fort Lauderdale
Type
Sexually Transmitted Diseases
340B ID
STD333052
Entity Address
3800 Inverrary Blve
109
Fort Lauderdale, FL 33319
Grant Number
NH25PS004342-04-01
Participating Start Date
9/17/2019
Last Recertification Date
5/9/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-2946
Pharmacy Address
2500 W. BROWARD BOULEVARD
FORT LAUDERDALE, FL 33312
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
4/27/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/17/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve Vixamar, COO
(954) 529-1178
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/14/2020
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