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AVITA PHARMACY 1058
CH045230 CARE SOUTH CAROLINA,INC
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Covered Entity Details
Entity Name
CARE SOUTH CAROLINA,INC
Subdivision Name
CareSouth Carolina Inc. Corporate Office
Type
HRSA-Funded Health Center
340B ID
CH045230
Entity Address
201 S 5th St
Hartsville, SC 29550-4211
Grant Number
H80CS00654
Participating Start Date
12/1/1992
Last Recertification Date
3/3/2025
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
4/17/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ann Lewis, CEO
(843) 857-0111
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/17/2019
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