Contract Pharmacy Details

WALGREEN CO.
RWI20825 Amity Medical Group, Inc

Covered Entity Details

Entity Name

Amity Medical Group, Inc

Subdivision Name

AMG1 Harris Blvd location

Type

Ryan White Part A

340B ID

RWI20825

Entity Address

6010 EAST W T HARRIS BLVD
CHARLOTTE, NC 28215-4084

Grant Number

H89HA11434

Participating Start Date

10/1/2016

Last Recertification Date

2/13/2025

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 07401
13720 HIGHWAY 74
INDIAN TRAIL, NC 28079-7600

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

AHMED ELGOHARY, MANAGER
(704) 506-6974

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/17/2016

340B Drug Pricing Program Database