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LONGS DRUGS OF LEXINGTON
RWII79601 Dignity Health Management Center, Inc.
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Covered Entity Details
Entity Name
Dignity Health Management Center, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII79601
Entity Address
402 Butternut St.
Abilene, TX 79602
Grant Number
X07HA00054
Participating Start Date
4/28/2022
Last Recertification Date
2/10/2025
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
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James Austin Wagstaff, Executive Director
(325) 672-3077 Ext: 9175708015
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
10/14/2020
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