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AVITA PHARMACY 1040
CH045770 Southeast Mississippi Rural Health Initiative, Inc.
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Covered Entity Details
Entity Name
Southeast Mississippi Rural Health Initiative, Inc.
Subdivision Name
SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Type
HRSA-Funded Health Center
340B ID
CH045770
Entity Address
5488 U S Highway 49
Hattiesburg, MS 39401-7806
Grant Number
H80CS00610
Participating Start Date
10/1/2002
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
4/11/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
GEROLDEAN DYSE, CEO
(601) 545-8700
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
4/11/2013
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