Contract Pharmacy Details

PROSPERITY PHARMACY MANASSAS
HV220311 INOVA HEALTH CARE SERVICES DBA INOVA JUNIPER PROGRAM

Covered Entity Details

Entity Name

INOVA HEALTH CARE SERVICES DBA INOVA JUNIPER PROGRAM

Subdivision Name

Type

Ryan White Part C

340B ID

HV220311

Entity Address

2740 Prosperity Avenue
SUITE 200
Fairfax, VA 22031

Grant Number

H76HA00177

Participating Start Date

1/1/2000

Last Recertification Date

3/4/2025

Pharmacy Details

Pharmacy Name

PROSPERITY PHARMACY MANASSAS

Pharmacy Address

PRINCE WILLIAM RX, INC
8644 SUDLEY RD STE 120
MANASSAS, VA 20110-4425

Pharmacy Comments

Contract Details

Approval Date

11/26/2012

Contract Begin Date

1/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/10/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Kylanne Green, Executive Vice President
(703) 645-2888

Contract Pharmacy Representative

Frank Odeh, President
(703) 517-4779

Signed By Date

10/11/2012

340B Drug Pricing Program Database