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AVITA PHARMACY 1029
STD76574 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
STD76574
Entity Address
115 W. 6th St.
Taylor, TX 76574
Grant Number
NH25PS005182
Participating Start Date
10/1/2019
Last Recertification Date
5/8/2025
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
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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