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AVITA PHARMACY 1040
STD752041 AIDS Arms, Inc. d/b/a Prism Health North Texas
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Covered Entity Details
Entity Name
AIDS Arms, Inc. d/b/a Prism Health North Texas
Subdivision Name
Oak Lawn Health Center
Type
Sexually Transmitted Diseases
340B ID
STD752041
Entity Address
2801 Lemmon Ave
Suite 200
Dallas, TX 75204
Grant Number
NH25PS005182
Participating Start Date
10/1/2019
Last Recertification Date
5/29/2025
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
7/16/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John T. Carlo, CEO
(214) 521-5191
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
7/16/2020
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