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LONGS DRUGS OF LEXINGTON
STD64106 BlaqOut, Inc.
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Covered Entity Details
Entity Name
BlaqOut, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD64106
Entity Address
517 Campbell Street
Kansas City, MO 64106
Grant Number
NH25PS005142
Participating Start Date
4/1/2020
Last Recertification Date
5/28/2025
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
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
D. Rashaan Gilmore, President/CEO
(816) 866-0355
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
7/15/2024
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