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AVITA PHARMACY 1073
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 1073
Pharmacy Address
AVITA DRUGS LLC DBA AVITA PHARMACY 1073
300 SOUTH 2ND STREET
SUIT 102
MCALLEN, TX 78501
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
7/1/2022
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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