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LONGS DRUGS OF LEXINGTON
RWI23704C Urban League of Hampton Roads
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Covered Entity Details
Entity Name
Urban League of Hampton Roads
Subdivision Name
Huntersville
Type
Ryan White Part A
340B ID
RWI23704C
Entity Address
830 Goff St
Norfolk, VA 23504
Grant Number
H89HA00053
Participating Start Date
1/1/2019
Last Recertification Date
3/3/2025
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
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/17/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Stephen L Williams, Medical Case Manager
(757) 627-0864
Contract Pharmacy Representative
PharmBlue, LLC
Joseph P. Pohl III, CEO
(724) 779-4720 Ext: 033
Signed By Date
7/14/2020
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