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PROPRIUM PHARMACY
STD235101 LGBT Life Center
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Covered Entity Details
Entity Name
LGBT Life Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD235101
Entity Address
5360 Robin Hood Rd
Suite 200
Norfolk, VA 23513
Grant Number
NU62PS924552
Participating Start Date
4/1/2017
Last Recertification Date
6/4/2024
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
PROPRIUM PHARMACY
Pharmacy Address
535 INDEPENDENCE PARKWAY
SUITE 400
CHESAPEAKE, VA 23320
Pharmacy Comments
Contract Details
Approval Date
10/10/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Stacie Walls-Beegle, Executive Director
(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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