Contract Pharmacy Details

LONGS DRUGS OF LEXINGTON
STD900101 special Service for Groups INC

Covered Entity Details

Entity Name

special Service for Groups INC

Subdivision Name

APAIT

Type

Sexually Transmitted Diseases

340B ID

STD900101

Entity Address

3055 Wilshire Blvd.
300
Los Angeles, CA 90010

Grant Number

U65PS004870

Participating Start Date

4/1/2020

Last Recertification Date

5/4/2020

Entity Termination Date

7/1/2021

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

3/2/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/9/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Abigail Radaza Proff, Senior Program Manager
(213) 553-1899

Contract Pharmacy Representative

AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587

Signed By Date

1/14/2020

340B Drug Pricing Program Database