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RXCP4 INC DBA AVANT PHARMACY AND WELLNES
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
RXCP4 INC DBA AVANT PHARMACY AND WELLNES
Pharmacy Address
824 LOWER DALLAS HWY
DALLAS, NC 28034
Pharmacy Comments
Contract Details
Approval Date
1/14/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Olivia Bentley, Executive Director
(704) 968-8353
Contract Pharmacy Representative
Avant Pharmacy and Wellness
Amina Abubakar, CEO
(704) 537-0909
Signed By Date
1/14/2023
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