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NPS PHARMACY AT ETSU
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
NPS PHARMACY AT ETSU
Pharmacy Address
615 N STATE OF FRANKLIN RD
JOHNSON CITY, TN 37604-8209
Pharmacy Comments
Contract Details
Approval Date
1/16/2020
Contract Begin Date
4/1/2020
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
NPS Pharmacy
Kevin Hartman, Pharm D
(615) 371-1210 Ext: 311
Signed By Date
1/16/2020
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