Contract Pharmacy Details

LONGS DRUGS OF LEXINGTON
RWII802201B Colorado Health Network, Inc.

Covered Entity Details

Entity Name

Colorado Health Network, Inc.

Subdivision Name

Northern Region

Type

Ryan White Part B

340B ID

RWII802201B

Entity Address

400 Remington St., Ste. 100
Fort Collins, CO 80524

Grant Number

X07HA00056

Participating Start Date

7/1/2020

Last Recertification Date

2/12/2025

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

7/15/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Darrell J Vigil, Chief Executive Officer
(303) 837-0166

Contract Pharmacy Representative

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

Signed By Date

7/15/2020

340B Drug Pricing Program Database