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LONGS DRUGS OF LEXINGTON
RWII55404 Rainbow Health Minnesota
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Covered Entity Details
Entity Name
Rainbow Health Minnesota
Subdivision Name
Type
Ryan White Part B
340B ID
RWII55404
Entity Address
701 S 4th Ave
Ste. 1500
Minneapolis, MN 55415
Grant Number
X07HA00028
Participating Start Date
10/1/2022
Last Recertification Date
1/30/2024
Entity Termination Date
4/1/2025
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
3/3/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeremy James Hanson Willis, CEO
(612) 373-2400 Ext: 6123065274
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
1/15/2021
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