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AVITA PHARMACY 1028
STD77036 Houston Health Department
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Covered Entity Details
Entity Name
Houston Health Department
Subdivision Name
Sharpstown Health Services
Type
Sexually Transmitted Diseases
340B ID
STD77036
Entity Address
6201 Bonhomme
Suite 300
Houston, TX 77036
Grant Number
NH25PS005182
Participating Start Date
7/1/2017
Last Recertification Date
5/7/2025
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
10/12/2018
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
10/12/2018
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