Contract Pharmacy Details

LONGS DRUGS OF LEXINGTON
STD84109 Hope on T.T.a.P.P.

Covered Entity Details

Entity Name

Hope on T.T.a.P.P.

Subdivision Name

Type

Sexually Transmitted Diseases

340B ID

STD84109

Entity Address

2468 E EVERGREEN AVE
Salt Lake City, UT 84109-3008

Grant Number

5NU51PS0051700400

Participating Start Date

4/1/2023

Last Recertification Date

5/8/2025

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

3/1/2023

Contract Begin Date

4/1/2023

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Sequan Kolibas, Executive Director
(801) 808-4260

Contract Pharmacy Representative

Avita
Chris Creamer, COO
(469) 592-2000

Signed By Date

1/11/2023

340B Drug Pricing Program Database