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AVITA PHARMACY 1028
STD78216 Texas Health Action
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Covered Entity Details
Entity Name
Texas Health Action
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78216
Entity Address
730 Isom Road
San Antonio, TX 78216
Grant Number
NH25PS005182
Participating Start Date
10/1/2017
Last Recertification Date
5/28/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher M Hamilton, CEO
(512) 647-6512
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, EVP
(504) 905-4587
Signed By Date
1/15/2020
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