Contract Pharmacy Details

AMC OHIO LLC #2
RWII43201D EQUITAS HEALTH

Covered Entity Details

Entity Name

EQUITAS HEALTH

Subdivision Name

MANSFIELD OFFICE

Type

Ryan White Part B

340B ID

RWII43201D

Entity Address

410 PARK AVE. WEST
SUITE 5
MANSFIELD, OH 44906

Grant Number

X07HA00016

Participating Start Date

1/1/2015

Last Recertification Date

2/20/2018

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

AMC OHIO LLC #2

Pharmacy Address

1222 S. PATTERSON BLVD
SUITE 110
DAYTON, OH 45402-2645

Pharmacy Comments

Contract Details

Approval Date

12/10/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Contract Pharmacy Representative

Aaron Clark, Director of Pharmacy Services
(614) 340-6776

Signed By Date

340B Drug Pricing Program Database