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AVITA DRUGS TENESSEE, LLC
STD38104 Friends For Life Corp
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Covered Entity Details
Entity Name
Friends For Life Corp
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD38104
Entity Address
1548 Poplar Ave
Memphis, TN 38104
Grant Number
1 NU65PS923764-01-00
Participating Start Date
10/1/2019
Last Recertification Date
5/22/2024
Pharmacy Details
Pharmacy Name
AVITA DRUGS TENESSEE, LLC
Pharmacy Address
DBA AVITA PHARMACY 1050
806 S COOPER ST
STE A
MEMPHIS, TN 38104
Pharmacy Comments
Contract Details
Approval Date
11/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Duke, Executive Director
(901) 333-8240
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
11/16/2019
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