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FOUNTAIN PLAZA PHARMACY DBA FOUNTAINRX
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
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
8/29/2022
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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