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AVITA PHARMACY 1044
HV0413130B Montgomery AIDS Outreach, Inc
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Covered Entity Details
Entity Name
Montgomery AIDS Outreach, Inc
Subdivision Name
Wellness Center
Type
Ryan White Part C
340B ID
HV0413130B
Entity Address
3050 McGehee Road
Montomery, AL 36111
Grant Number
H76HA00099
Participating Start Date
7/1/2019
Last Recertification Date
1/31/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1044
Pharmacy Address
AVITA DRUGS ALABAMA LLC D/B/A AVITA PHAR
3220 5TH AVE S STE 110
BIRMINGHAM, AL 35222-2309
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael R. Murphree, Chief Executive Officer
(334) 280-3349 Ext: 1001
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
1/9/2020
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