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WAL-MART PHARMACY WHSE #45
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
WAL-MART PHARMACY WHSE #45
Pharmacy Address
2250 NORTH 8TH STREET
SUITE 102-A
ROGERS, AR 72756
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
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/14/2023
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