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LONGS DRUGS OF LEXINGTON
STD900333 The Wall Las Memorias
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Covered Entity Details
Entity Name
The Wall Las Memorias
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD900333
Entity Address
2020 E. 1st Street
Los Angeles, CA 90033
Grant Number
NU62PS924569
Participating Start Date
10/1/2024
Last Recertification Date
5/5/2025
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
10/9/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard Zaldivar, Executive Director
(323) 257-1056 Ext: 27
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/9/2024
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