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AVITA PHARMACY 1043
RWII39202 My Brother's Keeper, Inc.
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Covered Entity Details
Entity Name
My Brother's Keeper, Inc.
Subdivision Name
Open Arms Healthcare Center
Type
Ryan White Part B
340B ID
RWII39202
Entity Address
805 East River Place
Jackson, MS 39202
Grant Number
5X07HA00036-33-00
Participating Start Date
10/1/2017
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1043
Pharmacy Address
AVITA DRUGS MISSISSIPPI LLC D/B/A AVITA
805 E RIVER PL STE A
JACKSON, MS 39202-3486
Pharmacy Comments
Contract Details
Approval Date
7/10/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
June Gipson, CEO
(769) 216-2455
Contract Pharmacy Representative
Avita Pharmacy Solution
mark Roth, Senior Account Executive
(504) 908-5932
Signed By Date
7/10/2019
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