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AVITA PHARMACY 1040
CHC26587-04 SAINT HOPE FOUNDATION
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Covered Entity Details
Entity Name
SAINT HOPE FOUNDATION
Subdivision Name
St. Hope Community Health Center- Dickinson
Type
HRSA-Funded Health Center
340B ID
CHC26587-04
Entity Address
3750 Medical Park Dr. STE 150
Dickinson, TX 77539
Grant Number
H80CS26587
Participating Start Date
4/1/2019
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
1/22/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Timika Sam-Cooper, Chief Operations Officer
(713) 778-1300 Ext: 2342
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
1/8/2019
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