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GRADY PONCE CENTER 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
GRADY PONCE CENTER PHARMACY
Pharmacy Address
341 PONCE DE LEON AVE NE, RM 1028
ATTN: PHARMACY
ATLANTA, GA 30308
Pharmacy Comments
04/25/2013 pharmacy address corrected, OPA internal system error inadvertantly changed record; 3/30/11 PHARM OPERATING NAME ADDED
Contract Details
Approval Date
7/1/2004
Contract Begin Date
7/1/2004
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MARISOL CRUZ, HIV CARE PROGRAM MANAGER
(404) 463-2453
Contract Pharmacy Representative
Signed By Date
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