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LONGS DRUGS OF LEXINGTON
STD187023 Wyoming Valley AIDS Council
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Covered Entity Details
Entity Name
Wyoming Valley AIDS Council
Subdivision Name
Old River Road Clinic
Type
Sexually Transmitted Diseases
340B ID
STD187023
Entity Address
250 Old River Road
C
Wilkes Barre, PA 18702
Grant Number
NH25PS005144-05-06
Participating Start Date
10/1/2023
Last Recertification Date
5/7/2025
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
10/1/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KEN J ZULA, EXECUTIVE DIRECTOR
(570) 823-5808 Ext: 302
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/1/2024
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