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KROGER PHARMACY #689
HV01710A AIDS Arms, Inc.d/b/a Prism Health North Texas
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Covered Entity Details
Entity Name
AIDS Arms, Inc.d/b/a Prism Health North Texas
Subdivision Name
South Dallas Clinic
Type
Ryan White Part C
340B ID
HV01710A
Entity Address
4922 Spring Ave
Dallas, TX 75210-1359
Grant Number
H76HA01710
Participating Start Date
7/1/2016
Last Recertification Date
3/3/2025
Pharmacy Details
Pharmacy Name
KROGER PHARMACY #689
Pharmacy Address
17194 PRESTON ROAD
DALLAS, TX 75248
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John T. Carlo, CEO
(214) 521-5191
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/12/2020
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