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AVITA PHARMACY 1040
CH040390 MEDLINK GEORGIA, INC.
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Covered Entity Details
Entity Name
MEDLINK GEORGIA, INC.
Subdivision Name
Medlink Colbert
Type
HRSA-Funded Health Center
340B ID
CH040390
Entity Address
11 CHARLIE MORRIS RD
COLBERT, GA 30628
Grant Number
H80CS00427
Participating Start Date
7/1/2005
Last Recertification Date
2/11/2025
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
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dave Ward, CEO
(706) 788-3234
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/9/2019
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