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PICH KTM CORP
RWI32207 River Region Human Services
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Covered Entity Details
Entity Name
River Region Human Services
Subdivision Name
Type
Ryan White Part A
340B ID
RWI32207
Entity Address
3901 Carmichael Avenue
Jacksonville, FL 32207
Grant Number
H89HA00039
Participating Start Date
7/1/2021
Last Recertification Date
2/26/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PICH KTM CORP
Pharmacy Address
DBA MEDTOWN PHARMACY
11643 BEACH BLVD
UNIT A
JACKSONVILLE, FL 32246
Pharmacy Comments
Contract Details
Approval Date
5/5/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jacqueline Dowdy Denise Dowdy, CEO
(850) 264-4701
Contract Pharmacy Representative
Medtown Pharmacy
Nakry Oeur, Owner
(904) 551-5870
Signed By Date
4/14/2021
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