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AVITA PHARMACY 1058
STD27604 Alliance of AIDS Services-Carolina
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Covered Entity Details
Entity Name
Alliance of AIDS Services-Carolina
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD27604
Entity Address
4 North Blount Street
100
Raleigh, NC 27601
Grant Number
6NH25PS005152-05-07
Participating Start Date
10/1/2018
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
8/2/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/28/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Melissa J Haithcox-Dennis, Executive Director
(919) 834-2437 Ext: 1001
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
7/24/2018
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