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AVITA PHARMACY 1038
STD701192 Brotherhood, Incorporated
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Covered Entity Details
Entity Name
Brotherhood, Incorporated
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD701192
Entity Address
2714 Canal Street
1422 Kelerec Street
Suite 503A
New Orleans, LA 70119
Grant Number
NU65PS004804
Participating Start Date
10/1/2019
Last Recertification Date
5/7/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Veronica Magee, Deputy Director
(504) 941-0231
Contract Pharmacy Representative
Pharm Blue
Samantha Possert, Southeast Regional Sales Executive
(813) 734-4023
Signed By Date
7/15/2020
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