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LONGS DRUGSTORES OF SC INC
STD29621 AID UPSTATE
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Covered Entity Details
Entity Name
AID UPSTATE
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD29621
Entity Address
118 MONTGOMERY DRIVE
ANDERSON, SC 29621
Grant Number
NH25PS005150
Participating Start Date
4/1/2017
Last Recertification Date
5/15/2025
Pharmacy Details
Pharmacy Name
LONGS DRUGSTORES OF SC INC
Pharmacy Address
D/B/A AVITA PHARMACY 1054
455 LAKESHORE PKWY
ROCK HILL, SC 29730-4205
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
B ANDREW HALL, CEO
(864) 250-0607 Ext: 6208
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/13/2018
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