Contract Pharmacy Details

AVITA PHARMACY 1039
RWIID70112 STD/HIV Program

Covered Entity Details

Entity Name

STD/HIV Program

Subdivision Name

OFFICE OF PUBLIC HEALTH

Type

Ryan White Part B ADAP Direct Purchase

340B ID

RWIID70112

Entity Address

1450 POYDRAS ST.
Suite 2136
NEW ORLEANS, LA 70112

Grant Number

X07HA00018

Participating Start Date

7/1/1998

Last Recertification Date

2/14/2025

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

1/15/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

DeAnn Gruber, Administrative Director Louisiana OPH STD/HIV Program
(504) 568-7474

Contract Pharmacy Representative

Avita Pharmacy
Keith Fox, Sr. Vice President
(225) 236-1540

Signed By Date

1/15/2019

340B Drug Pricing Program Database