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AVITA PHARMACY 1043
FP392020 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
Family Planning (Title X only)
340B ID
FP392020
Entity Address
805 East River Place
Jackson, MS 39202
Grant Number
FPHPA006550
Participating Start Date
10/1/2018
Last Recertification Date
5/23/2024
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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