Contract Pharmacy Details

M L K PHARMACY
RWII27101 AIDS Care Service

Covered Entity Details

Entity Name

AIDS Care Service

Subdivision Name

Type

Ryan White Part B

340B ID

RWII27101

Entity Address

995 West Northwest Blvd
Winston-Salem, NC 27101

Grant Number

X07HA00051

Participating Start Date

4/1/2015

Last Recertification Date

2/23/2017

Entity Termination Date

4/1/2017

Pharmacy Details

Pharmacy Name

M L K PHARMACY

Pharmacy Address

1489 NEW WALKERTOWN ROAD
WINSTON-SALEM, NC 27101-3319

Pharmacy Comments

Contract Details

Approval Date

7/14/2016

Contract Begin Date

10/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017

Contacts

Covered Entity Signing Official

Joan Sherrill, Business Manager
(336) 721-2128

Contract Pharmacy Representative

Pratik Shah, Owner
(336) 722-0077

Signed By Date

7/14/2016