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AVITA PHARMACY 1043
RWII354011A West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services
Type
Ryan White Part B
340B ID
RWII354011A
Entity Address
900 Stark Road
Starkville, MS 39759
Grant Number
X07HA00036
Participating Start Date
7/1/2020
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1043
Pharmacy Address
AVITA DRUGS MISSISSIPPI LLC D/B/A AVITA
805 E RIVER PL STE A
JACKSON, MS 39202-3486
Pharmacy Comments
Contract Details
Approval Date
8/10/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Billy Kirkpatrick, Chief Executive Officer
(205) 759-8470 Ext: 7
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
8/10/2020
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