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AVITA PHARMACY 1041
STD70508 Lafayette Foundation Clinic INC
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Covered Entity Details
Entity Name
Lafayette Foundation Clinic INC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD70508
Entity Address
117 Caillouet Place
Lafayette, LA 70501
Grant Number
NH25PS005176
Participating Start Date
4/1/2020
Last Recertification Date
5/6/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1041
Pharmacy Address
AVITA DRUGS LLC D/B/A AVITA PHARMACY 104
1715 COMMON ST STE A
LAKE CHARLES, LA 70601-6135
Pharmacy Comments
Contract Details
Approval Date
7/2/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Landry, Founder
(337) 988-9737
Contract Pharmacy Representative
Avita
Steve Sciortino, Senior Account Executive
(225) 335-4417
Signed By Date
7/2/2020
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