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AVITA PHARMACY 1040
HV01710B AIDS Arms, Inc. d/b/a Prism Health North Texas
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Covered Entity Details
Entity Name
AIDS Arms, Inc. d/b/a Prism Health North Texas
Subdivision Name
Uptown Clinic
Type
Ryan White Part C
340B ID
HV01710B
Entity Address
2801 Lemmon Ave
Suite 400
Dallas, TX 75204
Grant Number
H76HA01710
Participating Start Date
4/1/2019
Last Recertification Date
3/3/2025
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
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John T. Carlo, CEO
(214) 521-5191
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
4/15/2019
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