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AVITA PHARMACY 1029
FP392020 My Brother's Keeper, Inc
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Covered Entity Details
Entity Name
My Brother's Keeper, Inc
Subdivision Name
Open Arms Healthcare Center
Type
Family Planning (Title X only)
340B ID
FP392020
Entity Address
805 East River Place
Jackson, MS 39202
Grant Number
FPHPA006550
Participating Start Date
10/1/2018
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
June Gipson, CEO
(769) 216-2455
Contract Pharmacy Representative
Avita Pharmacy Solution
mark Roth, Senior Account Executive
(504) 908-5932
Signed By Date
10/15/2018
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