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LONGS DRUGS OF LEXINGTON
STD58103 Canopy Medical Clinic
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Covered Entity Details
Entity Name
Canopy Medical Clinic
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD58103
Entity Address
1411 32nd St S
Suite 1
Fargo, ND 58103
Grant Number
6NH25PS005181-03
Participating Start Date
1/1/2022
Last Recertification Date
5/6/2025
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
10/11/2022
Contract Begin Date
10/17/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Heidi Selzler-Echola, Medical Director/APRN
(701) 264-5200
Contract Pharmacy Representative
Avita Specialty Pharmacy
Karla Sisinni, Regional 340B Consultant
(814) 323-4229
Signed By Date
10/11/2022
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