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PROSPERITY OUTPATIENT PHARMACY
RW422151 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 D
340B ID
RW422151
Entity Address
2740 Prosperity Avenue
SUITE 200
Fairfax, VA 22032
Grant Number
H12HA23011
Participating Start Date
4/1/2007
Last Recertification Date
2/29/2016
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
PROSPERITY OUTPATIENT PHARMACY
Pharmacy Address
INOVA FAIRFAX HOSPITAL
3300 GALLOWS RD
SUITE CCW1300
FALLS CHURCH, VA 22042
Pharmacy Comments
11/21/2012 pharmacy update (was OUTPATIENT RX, INC. added suite)
Contract Details
Approval Date
4/1/2007
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
11/21/2012 - contract inactive from 5/14/2009 to 12/31/2012
Contract Termination Date
Termination Reason
6/30/2016
Pharmacy closed
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
11/21/2012
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