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AVITA PHARMACY 1073
STD782121 Texas Health Action
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Covered Entity Details
Entity Name
Texas Health Action
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD782121
Entity Address
1219 McCullough
San Antonio, TX 78212
Grant Number
1H25PS004360-02
Participating Start Date
10/1/2017
Last Recertification Date
5/15/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1073
Pharmacy Address
AVITA DRUGS LLC DBA AVITA PHARMACY 1073
300 SOUTH 2ND STREET
SUIT 102
MCALLEN, TX 78501
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
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
7/9/2018
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