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AVITA PHARMACY 1039
HV12908 NO/AIDS TASK FORCE
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Covered Entity Details
Entity Name
NO/AIDS TASK FORCE
Subdivision Name
CrescentCare - St. Roch
Type
Ryan White Part C
340B ID
HV12908
Entity Address
1631 ELYSIAN FIELDS AVE
NEW ORLEANS, LA 70117
Grant Number
H76HA12908
Participating Start Date
1/1/2013
Last Recertification Date
3/7/2025
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
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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