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WAYFIELD PHARMACY
RWIID303031 GEORGIA DEPT OF PUBLIC HEALTH
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Covered Entity Details
Entity Name
GEORGIA DEPT OF PUBLIC HEALTH
Subdivision Name
Type
Ryan White Part B ADAP Direct Purchase
340B ID
RWIID303031
Entity Address
200 Piedmont Ave. SE
West Tower
Suite 1508
ATLANTA, GA 30334
Grant Number
X07HA22709
Participating Start Date
4/1/1997
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAYFIELD PHARMACY
Pharmacy Address
3050 MARTIN LUTHER KING JR DRIVE
UNIT H
ATLANTA, GA 30311
Pharmacy Comments
Contract Details
Approval Date
10/20/2010
Contract Begin Date
10/20/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/10/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MARISOL CRUZ, HIV CARE PROGRAM MANAGER
(404) 463-2453
Contract Pharmacy Representative
Wayfield Pharmacy
BIBI NWABUDE, PHARMACIST
(770) 992-9940
Signed By Date
10/6/2010
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