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WALGREEN CO.
RWI20825C Amity Medical Group, Inc
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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
WALGREEN CO.
Pharmacy Address
WALGREENS #17386
3716 W W T HARRIS BLVD STE J
CHARLOTTE, NC 28269-8517
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
4/29/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Olivia Bentley, Executive Director
(704) 968-8353
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2022
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