Contract Pharmacy Details

AVITA PHARMACY 1029
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 1029

Pharmacy Address

340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034

Pharmacy Comments

Contract Details

Approval Date

11/14/2012

Contract Begin Date

1/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/31/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

RAELINE NOBLES, EXECUTIVE DIRECTOR
(214) 521-5191

Contract Pharmacy Representative

Avita Drugs
KEITH FOX, CFO
(225) 236-1540

Signed By Date

10/4/2012

340B Drug Pricing Program Database