340B Drug Pricing Program Database
AVITA PHARMACY 1040
CH090090 MARIPOSA COMMUNITY HEALTH CENTER, INC. - information as of 5/27/2025 2:47:44 PM
Covered Entity Details
Entity Name
MARIPOSA COMMUNITY HEALTH CENTER, INC.
Subdivision Name
MARIPOSA COMMUNITY HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH090090
Entity Address
1852 N Mastick Way
Nogales, AZ 85621-1063
Grant Number
H80CS00752
Participating Start Date
12/1/1992
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Prevost, CEO
(520) 281-1550 Ext: 1005
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/17/2023
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