Contract Pharmacy Details

WALGREENS SPECIALTY PHARMACY, LLC
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

WALGREENS SPECIALTY PHARMACY, LLC

Pharmacy Address

ALLIANCERX WALGREENS PRIME #12314
9775 SW GEMINI DR, STE 1
BEAVERTON, OR 97008

Pharmacy Comments

Contract Details

Approval Date

7/15/2022

Contract Begin Date

10/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/15/2022
Agreement registered in error

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

340B Drug Pricing Program Database