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PROPRIUM PHARMACY
RWI23669 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI23669
Entity Address
20 Settlers Landing
Hampton, VA 23669
Grant Number
H89HA00053
Participating Start Date
1/1/2018
Last Recertification Date
1/29/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
PROPRIUM PHARMACY
Pharmacy Address
535 INDEPENDENCE PARKWAY
SUITE 400
CHESAPEAKE, VA 23320
Pharmacy Comments
Contract Details
Approval Date
11/21/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, CEO
(757) 640-0929 Ext: 215
Contract Pharmacy Representative
Sentara
Melissa Gallegos, Operations Manager
(757) 553-3514
Signed By Date
10/10/2017
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