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#109 MARKET 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
#109 MARKET PHARMACY
Pharmacy Address
NAIK, RAJESH C
209 EDGEWOOD AVE, SE
ATLANTA, GA 30303
Pharmacy Comments
Contract Details
Approval Date
1/24/2008
Contract Begin Date
1/24/2008
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/13/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
MARISOL CRUZ, HIV CARE PROGRAM MANAGER
(404) 463-2453
Contract Pharmacy Representative
Signed By Date
11/15/2007
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