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WAL-MART PHARMACY 10-2962
STD330601 Independent Medical Group, LLC
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Covered Entity Details
Entity Name
Independent Medical Group, LLC
Subdivision Name
Coconut Creek
Type
Sexually Transmitted Diseases
340B ID
STD330601
Entity Address
3880 Coconut Creek Parkway
Unit 100
Coconut Creek, FL 33060
Grant Number
NH25PS004342-04-01
Participating Start Date
9/19/2019
Last Recertification Date
5/18/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2962
Pharmacy Address
2300 WEST ATLANTIC BLVD
POMPANO BEACH, FL 33069
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
7/1/2023
Covered Entity Terminated
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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