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AVITA PHARMACY 1029
STD78626 Williamson County and Cities Health District
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Covered Entity Details
Entity Name
Williamson County and Cities Health District
Subdivision Name
Clinical Services
Type
Sexually Transmitted Diseases
340B ID
STD78626
Entity Address
100 W 3rd Street
Georgetown, TX 78626
Grant Number
NH25PS005182
Participating Start Date
10/1/2019
Last Recertification Date
5/13/2022
Entity Termination Date
7/1/2023
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
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lori Lynn Palazzo, Medical Director/Local Health Authority
(512) 248-3250
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
10/15/2019
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