Contract Pharmacy Details

AVITA PHARMACY 1028
RW424837B0 AIDS Arms, Inc. d/b/a Prism Health North Texas

Covered Entity Details

Entity Name

AIDS Arms, Inc. d/b/a Prism Health North Texas

Subdivision Name

Uptown Clinic

Type

Ryan White Part D

340B ID

RW424837B0

Entity Address

2801 Lemmon Ave
400
Dallas, TX 75204

Grant Number

H12HA24837

Participating Start Date

7/1/2019

Last Recertification Date

2/10/2022

Entity Termination Date

10/1/2022

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

Contract Termination Date
Termination Reason

9/10/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

John T. Carlo, CEO
(214) 521-5191

Contract Pharmacy Representative

Avita Drugs
KEITH FOX, CFO
(225) 236-1540

Signed By Date

4/15/2019

340B Drug Pricing Program Database