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AVITA PHARMACY 1029
RWII787520A Waterloo Counseling Center
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Covered Entity Details
Entity Name
Waterloo Counseling Center
Subdivision Name
Type
Ryan White Part B
340B ID
RWII787520A
Entity Address
314 East Highland Mall Blvd.
Suite 301
Austin, TX 78752
Grant Number
XO7HA00054
Participating Start Date
10/1/2018
Last Recertification Date
1/28/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
8/27/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Carol L Drennan, Executive Director
(512) 444-9922 Ext: 5124449922
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
7/17/2018
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