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FOUNTAIN PLAZA PHARMACY DBA FOUNTAINRX
RWI20825B Amity Medical Group, Inc
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Covered Entity Details
Entity Name
Amity Medical Group, Inc
Subdivision Name
AMG3 Monroe Rd location
Type
Ryan White Part A
340B ID
RWI20825B
Entity Address
9835 Monroe Rd
Suite B
Charlotte, NC 28270
Grant Number
H89HA11434
Participating Start Date
4/1/2021
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
FOUNTAIN PLAZA PHARMACY DBA FOUNTAINRX
Pharmacy Address
2825 W. ANDREW JOHNSON HWY.
MORRISTOWN, TN 37814
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Olivia Bentley, Executive Director
(704) 968-8353
Contract Pharmacy Representative
Fountain Plaza Pharmacy
Joseph Huntsman, CEO
(423) 307-5757
Signed By Date
7/15/2022
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