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AVITA PHARMACY 1028
RWI78752 Vivent Health Texas, Inc.
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Covered Entity Details
Entity Name
Vivent Health Texas, Inc.
Subdivision Name
AIDS Services of Austin
Type
Ryan White Part A
340B ID
RWI78752
Entity Address
104 E Highland Mall Blvd
Suite 100
Austin, TX 78752
Grant Number
H89HA00036
Participating Start Date
10/1/2018
Last Recertification Date
2/23/2025
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
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Scott, C.E.O.
(512) 458-2437
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
10/15/2018
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