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WALMART PHARMACY 10-4148
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
WALMART PHARMACY 10-4148
Pharmacy Address
8800 EAST WT HARRIS BLVD
CHARLOTTE, NC 28227
Pharmacy Comments
Contract Details
Approval Date
7/5/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Olivia Bentley, Executive Director
(704) 968-8353
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
7/5/2024
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