Contract Pharmacy Details

AVITA PHARMACY 1028
RWI75208 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

Oak Cliff Clinic

Type

Ryan White Part A

340B ID

RWI75208

Entity Address

219 SUNSET, SUITE 116A
DALLAS, TX 75208-4531

Grant Number

H89HA00014

Participating Start Date

1/1/2002

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

10/31/2011

Contract Begin Date

10/31/2011

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

RAELINE NOBLES, EXECUTIVE DIRECTOR
(214) 521-5191

Contract Pharmacy Representative

MIKE MCBRIDE, VP OF BUSINESS DEVELOPMENT
(225) 924-1930

Signed By Date

10/27/2011

340B Drug Pricing Program Database