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PROSPERITY PHARMACY FAIRFAX
RWII22151 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 B
340B ID
RWII22151
Entity Address
2740 Prosperity Avenue
SUITE 200
Fairfax, VA 22032
Grant Number
X07HA00009
Participating Start Date
10/1/2019
Last Recertification Date
1/30/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
PROSPERITY PHARMACY FAIRFAX
Pharmacy Address
2740 PROSPERITY AVE
SUITE 200
FAIRFAX, VA 22031
Pharmacy Comments
Contract Details
Approval Date
4/5/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Contacts
Covered Entity Signing Official
Karen Berube, VP Population Health
(703) 698-2545
Contract Pharmacy Representative
Frank Odeh, President
(703) 517-4779
Signed By Date
4/5/2016
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