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AVITA PHARMACY 1029
STD77009 Houston Health Department
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Covered Entity Details
Entity Name
Houston Health Department
Subdivision Name
La Nueva Casa Health Center
Type
Sexually Transmitted Diseases
340B ID
STD77009
Entity Address
1809 N. Main
Houston, TX 77009
Grant Number
NH25PS005182
Participating Start Date
4/1/2020
Last Recertification Date
5/7/2025
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
7/6/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephen L. Williams, Executive Director
(832) 393-5056
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
7/6/2020
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