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LONG'S DEKALB HEALTH PHARMACY
HV00100 Ware County Board of Health
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Covered Entity Details
Entity Name
Ware County Board of Health
Subdivision Name
Toombs Wellness Center
Type
Ryan White Part C
340B ID
HV00100
Entity Address
714 NW Broad St.
Lyons, GA 30436
Grant Number
H76HA00100
Participating Start Date
1/1/2016
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
LONG'S DEKALB HEALTH PHARMACY
Pharmacy Address
AVITA PHARMACY 1045
1428 SCOTT BLVD
DECATUR, GA 30030
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/28/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Rosemarie Parks, District Health Director
(912) 285-6002
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/14/2020
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