Contract Pharmacy Details

LONGS DRUGS OF LEXINGTON
RWI606162 Alliance Care 360

Covered Entity Details

Entity Name

Alliance Care 360

Subdivision Name

Type

Ryan White Part A

340B ID

RWI606162

Entity Address

2929 S Wabash Avenue,
Suite
202
Chicago, IL 60616-3243

Grant Number

H89HA00008

Participating Start Date

7/1/2018

Last Recertification Date

2/3/2024

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

4/15/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/15/2021
Agreement registered in error

Contacts

Covered Entity Signing Official

Ariq Cabbler, Director
(312) 808-1044 Ext: 101

Contract Pharmacy Representative

Avita Pharmacy
Angel Scheider, Executive
(847) 354-5847

Signed By Date

4/15/2021

340B Drug Pricing Program Database