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LONGS DRUGS OF LEXINGTON
RWI30311A Heather Ivy Society
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Covered Entity Details
Entity Name
Heather Ivy Society
Subdivision Name
Heather Ivy Society
Type
Ryan White Part A
340B ID
RWI30311A
Entity Address
381 Forest Parkway
Suite B
Forest Park, GA 30297
Grant Number
UT8HA33933
Participating Start Date
4/1/2025
Last Recertification Date
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
2/11/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Zandraetta Tims-Cook, Executive Director
(844) 884-9691 Ext: 1
Contract Pharmacy Representative
Avita
Shawn Smith, Sr Account Executive
(305) 906-2937
Signed By Date
1/7/2025
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