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AVITA PHARMACY 1058
RWII35233 Birmingham AIDS Outreach, Inc.
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Covered Entity Details
Entity Name
Birmingham AIDS Outreach, Inc.
Subdivision Name
Magic City Wellness Center
Type
Ryan White Part B
340B ID
RWII35233
Entity Address
3220 5th Avenue South
Suite 100
Birmingham, AL 35222
Grant Number
X07HA00049
Participating Start Date
10/1/2016
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
10/7/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KAREN MUSGROVE, EXECUTIVE DIRECTOR
(205) 322-4197
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
10/7/2016
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