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AVITA PHARMACY 1028
FQHCLA401 ACADIANA CARES INC
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Covered Entity Details
Entity Name
ACADIANA CARES INC
Subdivision Name
Acadiana Cares
Type
Health Center Program Look-Alike
340B ID
FQHCLA401
Entity Address
809 Martin Luther King Jr Dr
Lafayette, LA 70501-1884
Grant Number
LALCS33404
Participating Start Date
1/1/2020
Last Recertification Date
2/18/2025
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
12/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Claude Martin, CEO
(337) 233-2437 Ext: 125
Contract Pharmacy Representative
Avita Drugs
Jerry Purcell, Executive Vice President
(504) 905-4587
Signed By Date
10/14/2019
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