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AVITA PHARMACY 1028
STD752041 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
Oak Lawn Health Center
Type
Sexually Transmitted Diseases
340B ID
STD752041
Entity Address
2801 Lemmon Ave
Suite 200
Dallas, TX 75204
Grant Number
NH25PS005182
Participating Start Date
10/1/2019
Last Recertification Date
5/14/2024
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
9/4/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
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
7/2/2019
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