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PROPRIUM PHARMACY
RWII23510 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Ryan White Part B
340B ID
RWII23510
Entity Address
1001 Monticello Ave.
Suite 100
Norfolk, VA 23510
Grant Number
X07HA00009
Participating Start Date
4/1/2019
Last Recertification Date
2/21/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
PROPRIUM PHARMACY
Pharmacy Address
535 INDEPENDENCE PARKWAY
SUITE 400
CHESAPEAKE, VA 23320
Pharmacy Comments
Contract Details
Approval Date
4/22/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, CEO
(757) 640-0929 Ext: 215
Contract Pharmacy Representative
Sentara Enterprises
Jim R Schwamburger, Director
(757) 553-3211
Signed By Date
4/22/2019
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