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PROSPERITY PHARMACY FAIRFAX
HV220311D Inova Juniper Program
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Covered Entity Details
Entity Name
Inova Juniper Program
Subdivision Name
Falls Church
Type
Ryan White Part C
340B ID
HV220311D
Entity Address
500 North Washington Street
Suite 200
Falls Church, VA 22046
Grant Number
H76HA00177
Participating Start Date
7/1/2016
Last Recertification Date
2/18/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
PROSPERITY PHARMACY FAIRFAX
Pharmacy Address
2740 PROSPERITY AVE
SUITE 200
FAIRFAX, VA 22031
Pharmacy Comments
Contract Details
Approval Date
4/25/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Frank Odeh, President
(703) 517-4779
Signed By Date
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