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PROSPERITY PHARMACY MANASSAS
RWI22151 INOVA HEALTH CARE SERVICES DBA INOVA JUNIPER PROGRAM
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Covered Entity Details
Entity Name
INOVA HEALTH CARE SERVICES DBA INOVA JUNIPER PROGRAM
Subdivision Name
Type
Ryan White Part A
340B ID
RWI22151
Entity Address
9304 Forest Point Circle
Manassas, VA 20110
Grant Number
DC EMA
Participating Start Date
1/1/2012
Last Recertification Date
2/5/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
PROSPERITY PHARMACY MANASSAS
Pharmacy Address
PRINCE WILLIAM RX, INC
8644 SUDLEY RD STE 120
MANASSAS, VA 20110-4425
Pharmacy Comments
Contract Details
Approval Date
11/26/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kylanne Green, Executive Vice President
(703) 645-2888
Contract Pharmacy Representative
Frank Odeh, President
(703) 517-4779
Signed By Date
10/11/2012
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