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AVITA PHARMACY 1028
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 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
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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