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AVITA PHARMACY 1028
STD78759 Texas Health Action
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Covered Entity Details
Entity Name
Texas Health Action
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78759
Entity Address
8140 N Mopac Expy
Bldg 2
Ste 130
Austin, TX 78759
Grant Number
NH25PS005182
Participating Start Date
10/1/2018
Last Recertification Date
6/1/2023
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
7/26/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joe McAdams, Executive Director
(512) 939-2645
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
7/6/2018
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