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AVITA PHARMACY 1039
RWI70119A NO/AIDS Task Force (d.b.a) CrescentCare
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Covered Entity Details
Entity Name
NO/AIDS Task Force (d.b.a) CrescentCare
Subdivision Name
Family Care Services Center
Type
Ryan White Part A
340B ID
RWI70119A
Entity Address
1631 ELYSIAN FIELDS AVE
New Orleans, LA 70117
Grant Number
H89HA00035
Participating Start Date
1/1/2015
Last Recertification Date
2/11/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1039
Pharmacy Address
1631 ELYSIAN FIELDS AVE STE 200
NEW ORLEANS, LA 70117-8208
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
NOEL John TWILBECK, CEO
(504) 821-2601 Ext: 1000
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
1/3/2019
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