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AVANT PHARMACY AND WELLNESS
FQHCLA460C AMITY MEDICAL GROUP INC
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Covered Entity Details
Entity Name
AMITY MEDICAL GROUP INC
Subdivision Name
AMG4 Dallas
Type
Health Center Program Look-Alike
340B ID
FQHCLA460C
Entity Address
824 Lower Dallas Hwy
Dallas, NC 28034-9368
Grant Number
LALCS48999
Participating Start Date
4/1/2024
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
AVANT PHARMACY AND WELLNESS
Pharmacy Address
2300 RANDOLPH RD UNIT A-2
CHARLOTTE, NC 28207
Pharmacy Comments
Contract Details
Approval Date
4/14/2024
Contract Begin Date
7/1/2024
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
4/14/2024
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