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AVITA PHARMACY 1038
CHC33653-04 Baptist Community Health Services, Inc.
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Covered Entity Details
Entity Name
Baptist Community Health Services, Inc.
Subdivision Name
Baptist Community Health Services- Mandeville
Type
HRSA-Funded Health Center
340B ID
CHC33653-04
Entity Address
1437 W Causeway Approach
Mandeville, LA 70471-3045
Grant Number
H80CS33653
Participating Start Date
4/1/2020
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
2/28/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shawn Powers, CEO
(682) 249-4128
Contract Pharmacy Representative
Avita Pharmacy Solution
mark Roth, Senior Account Executive
(504) 908-5932
Signed By Date
1/15/2020
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