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AVITA PHARMACY 1038
STD706012 Southwest Louisiana AIDS Council
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Covered Entity Details
Entity Name
Southwest Louisiana AIDS Council
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD706012
Entity Address
425 Kingsley Street
Lake Charles, LA 70601
Grant Number
NH25PS005176
Participating Start Date
10/1/2023
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
4/29/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Terry L. Estes, Executive Director
(337) 439-5861
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/9/2019
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