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AVITA PHARMACY 1040
FP77093 Houston Health Department
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Covered Entity Details
Entity Name
Houston Health Department
Subdivision Name
NORTHSIDE HEALTH CENTER
Type
Family Planning (Title X only)
340B ID
FP77093
Entity Address
Northiside Health Center
8504 Schuller Road
HOUSTON, TX 77093
Grant Number
FPHPA006521
Participating Start Date
10/1/2004
Last Recertification Date
5/7/2025
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
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephen L. Williams, Executive Director
(832) 393-5056
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
10/11/2018
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