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AVITA PHARMACY 1041
HV26854 Southwest Louisiana AIDS Council
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Covered Entity Details
Entity Name
Southwest Louisiana AIDS Council
Subdivision Name
n/a
Type
Ryan White Part C
340B ID
HV26854
Entity Address
425 Kingsley Street
Lake Charles, LA 70601
Grant Number
H76HA26854
Participating Start Date
10/1/2014
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1041
Pharmacy Address
AVITA DRUGS LLC D/B/A AVITA PHARMACY 104
1715 COMMON ST STE A
LAKE CHARLES, LA 70601-6135
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry L. Estes, Executive Director
(337) 439-5861
Contract Pharmacy Representative
Avita
Keisha Taylor, Assistant Pharmacist
(225) 226-0210
Signed By Date
10/11/2019
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