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AVITA PHARMACY 1073
STD78664 Williamson County and Cities Health District
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Covered Entity Details
Entity Name
Williamson County and Cities Health District
Subdivision Name
Clinical Services
Type
Sexually Transmitted Diseases
340B ID
STD78664
Entity Address
355 Texas Ave
Round Rock, TX 78664
Grant Number
NH25PS005182
Participating Start Date
7/1/2019
Last Recertification Date
5/8/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1073
Pharmacy Address
AVITA DRUGS LLC DBA AVITA PHARMACY 1073
300 SOUTH 2ND STREET
SUIT 102
MCALLEN, TX 78501
Pharmacy Comments
Contract Details
Approval Date
5/2/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/4/2019
CE terminated due to audit finding
Contacts
Covered Entity Signing Official
Lori Lynn Palazzo, Medical Director/Local Health Authority
(512) 248-3250
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
4/4/2019
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