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AVITA PHARMACY 1029
STD770041 AIDS Foundation Houston, Inc.
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Covered Entity Details
Entity Name
AIDS Foundation Houston, Inc.
Subdivision Name
Richmond
Type
Sexually Transmitted Diseases
340B ID
STD770041
Entity Address
5751 Blythewood Street
Suite 200
Houston, TX 77021
Grant Number
1 NU62PS924685-01-00
Participating Start Date
7/1/2019
Last Recertification Date
5/16/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
6/14/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nicholas Williams, CFO
(713) 623-6796 Ext: 285
Contract Pharmacy Representative
Avita Drugs
Jerry Purcell, Executive Vice President
(504) 905-4587
Signed By Date
4/11/2019
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