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LEGACY RX II
STD735011 LEGACY WELLNESS CENTER
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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 II
Pharmacy Address
2809 NW 31ST ST
OKLAHOMA CITY, OK 73112
Pharmacy Comments
Contract Details
Approval Date
1/14/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JENNIFER LE, APRN
(405) 615-8967
Contract Pharmacy Representative
LEGACY RX II
HENRY THAI, PHARMACIST
(405) 900-5200
Signed By Date
1/14/2025
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