Contract Pharmacy Details

AVITA PHARMACY 1040
RWI90010 Special Service for Groups INC

Covered Entity Details

Entity Name

Special Service for Groups INC

Subdivision Name

APAIT

Type

Ryan White Part A

340B ID

RWI90010

Entity Address

3055 Wilshire Blvd.
300
Los Angeles, CA 90010

Grant Number

H89HA00016

Participating Start Date

4/1/2020

Last Recertification Date

Entity Termination Date

4/1/2021

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

3/5/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/9/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Abigail Radaza Proff, Senior Program Manager
(213) 553-1899

Contract Pharmacy Representative

AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587

Signed By Date

1/14/2020

340B Drug Pricing Program Database