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LONG'S KILBOURNE ROAD PHARMACY
CHC28972-03 AFFINITY HEALTH CENTER
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Covered Entity Details
Entity Name
AFFINITY HEALTH CENTER
Subdivision Name
Catawba Care Fort Mill Site
Type
HRSA-Funded Health Center
340B ID
CHC28972-03
Entity Address
120 ELLIOTT ST E
FORT MILL, SC 29715-1848
Grant Number
H80CS28972
Participating Start Date
1/1/2016
Last Recertification Date
2/23/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
LONG'S KILBOURNE ROAD PHARMACY
Pharmacy Address
D/B/A AVITA PHARMACY 1053
630 KILBOURNE RD
COLUMBIA, SC 29205-2827
Pharmacy Comments
Contract Details
Approval Date
10/5/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Anita Case, Executive Director
(803) 909-9710
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
10/5/2017
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