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Walmart Pharmacy 10-7611
FQHCLA460D AMITY MEDICAL GROUP INC
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Covered Entity Details
Entity Name
AMITY MEDICAL GROUP INC
Subdivision Name
AMG - N Tryon Rd
Type
Health Center Program Look-Alike
340B ID
FQHCLA460D
Entity Address
7945 N. Tryon St # 112
Charlotte, NC 28262-3587
Grant Number
LALCS48999
Participating Start Date
1/1/2025
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
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
10/15/2024
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