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AVITA PHARMACY 1040
FQHCLA405A Cascade Aids Project
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Covered Entity Details
Entity Name
Cascade Aids Project
Subdivision Name
Cascade AIDS Project
Type
Health Center Program Look-Alike
340B ID
FQHCLA405A
Entity Address
520 NW Davis St Ste 215
Portland, OR 97209-3620
Grant Number
LALCS33965
Participating Start Date
7/1/2020
Last Recertification Date
2/24/2025
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
4/2/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tyler A. TerMeer, Executive Director
(503) 278-3810
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/1/2020
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