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AVITA PHARMACY 1029
RWII77901 Victoria County Public Health Department
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Covered Entity Details
Entity Name
Victoria County Public Health Department
Subdivision Name
HARP of Victoria
Type
Ryan White Part B
340B ID
RWII77901
Entity Address
2805 N Navarro St
Ste 104
Victoria, TX 77901
Grant Number
X07HA00054
Participating Start Date
4/1/2017
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Victoria Reyna, Program Manager
(361) 578-6281 Ext: 3802
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/9/2020
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