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LONGS DRUGS OF LEXINGTON
FQHCLA382 LAGUNA BEACH COMMUNITY CLINIC INC
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Covered Entity Details
Entity Name
LAGUNA BEACH COMMUNITY CLINIC INC
Subdivision Name
Laguna Beach Community Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA382
Entity Address
362 Third Street
Laguna Beach, CA 92651
Grant Number
LALCS32582
Participating Start Date
4/1/2019
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
4/12/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jorge Rubal, C.E.O. / C.M.O.
(949) 494-0761 Ext: 132
Contract Pharmacy Representative
Avita
Dean Wilson, Account Executive, Pacific Southwest Region
(214) 957-4327
Signed By Date
4/12/2022
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