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WALMART PHARMACY 10-5169
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
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
10/15/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Olivia Bentley, Executive Director
(704) 968-8353
Contract Pharmacy Representative
CVS
Courtney Wilson, Representative
(817) 201-1395
Signed By Date
10/15/2023
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