Contract Pharmacy Details

LEGACY RX
STD735011 LEGACY WELLNESS CENTER

Covered Entity Details

Entity Name

LEGACY WELLNESS CENTER

Subdivision Name

Type

Sexually Transmitted Diseases

340B ID

STD735011

Entity Address

927 SW D AVE
LAWTON, OK 73501

Grant Number

NU62PS924721

Participating Start Date

1/1/2024

Last Recertification Date

5/20/2024

Pharmacy Details

Pharmacy Name

LEGACY RX

Pharmacy Address

LEGACY RX
927 SW D AVE
LAWTON, OK 73501

Pharmacy Comments

Contract Details

Approval Date

4/13/2024

Contract Begin Date

7/1/2024

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

JENNIFER LE, APRN
(405) 615-8967

Contract Pharmacy Representative

LEGACY RX
HENRY THAI, PHARMACIST
(580) 699-8052

Signed By Date

4/13/2024