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AVITA PHARMACY 1028
STD770572 AIDS Foundation Houston, Inc. DBA/ Allies in Hope
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Covered Entity Details
Entity Name
AIDS Foundation Houston, Inc. DBA/ Allies in Hope
Subdivision Name
Westpark
Type
Sexually Transmitted Diseases
340B ID
STD770572
Entity Address
6260 Westpark Drive
100
Houston, TX 77057
Grant Number
5 NU62PS9246850400
Participating Start Date
7/1/2019
Last Recertification Date
5/14/2025
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
6/14/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
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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