Contract Pharmacy Details

NORTH CAROLINA CVS PHARMACY, L.L.C.
RWI20825C Amity Medical Group, Inc

Covered Entity Details

Entity Name

Amity Medical Group, Inc

Subdivision Name

AMG4 Dallas location

Type

Ryan White Part A

340B ID

RWI20825C

Entity Address

824 Lower Dallas Hwy
Dallas, NC 28034

Grant Number

H89HA11434

Participating Start Date

6/9/2022

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

NORTH CAROLINA CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03694
2325 VILLAGE LAKE DR.
CHARLOTTE, NC 28212

Pharmacy Comments

Contract Details

Approval Date

7/15/2022

Contract Begin Date

8/29/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/12/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

Olivia Bentley, Executive Director
(704) 968-8353

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/15/2022

340B Drug Pricing Program Database