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AVITA PHARMACY 1029
STD770361 AIDS Foundation Houston, Inc.
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Covered Entity Details
Entity Name
AIDS Foundation Houston, Inc.
Subdivision Name
FLAS
Type
Sexually Transmitted Diseases
340B ID
STD770361
Entity Address
6666 Harwin Drive
370
Houston, TX 77036
Grant Number
1 NU62PS924685-01-00
Participating Start Date
7/1/2019
Last Recertification Date
5/13/2022
Entity Termination Date
10/1/2022
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
10/1/2022
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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