Contract Pharmacy Details

LONGS DRUGS OF LEXINGTON
RW424799 SisterLove, Inc.

Covered Entity Details

Entity Name

SisterLove, Inc.

Subdivision Name

Atlanta

Type

Ryan White Part D

340B ID

RW424799

Entity Address

3709 Bakers Ferry Rd Sw
Atlanta, GA 30331

Grant Number

2H12HA24799-06-00

Participating Start Date

4/1/2018

Last Recertification Date

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

LONGS DRUGS OF LEXINGTON

Pharmacy Address

D/B/A AVITA PHARMACY 1051
1216 W MAIN ST
STE D
LEXINGTON, SC 29072-2453

Pharmacy Comments

Contract Details

Approval Date

4/24/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Dazon Dixon Diallo, Founder/President
(404) 505-7777

Contract Pharmacy Representative

Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587

Signed By Date

4/24/2018

340B Drug Pricing Program Database