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PROSPERITY PHARMACY FAIRFAX
RWI22151B Inova Juniper Program
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Covered Entity Details
Entity Name
Inova Juniper Program
Subdivision Name
Leesburg
Type
Ryan White Part A
340B ID
RWI22151B
Entity Address
211 Gibson Street NW, Suite 206
Leesburg, VA 20176
Grant Number
H89HA00053
Participating Start Date
7/1/2016
Last Recertification Date
2/5/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
PROSPERITY PHARMACY FAIRFAX
Pharmacy Address
2740 PROSPERITY AVE
SUITE 200
FAIRFAX, VA 22031
Pharmacy Comments
Contract Details
Approval Date
4/19/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Frank Odeh, President
(703) 517-4779
Signed By Date
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