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REVAN RX
RWII75219 Resource Center of Dallas
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Covered Entity Details
Entity Name
Resource Center of Dallas
Subdivision Name
Type
Ryan White Part B
340B ID
RWII75219
Entity Address
2701 Reagan Street
Dallas, TX 75219
Grant Number
X07HA00054
Participating Start Date
7/1/2015
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
REVAN RX
Pharmacy Address
REVAN INC
5601 NW 72ND ST STE 142
WARR ACRES, OK 73132-5923
Pharmacy Comments
Contract Details
Approval Date
10/2/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/26/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Marisa Elliott, Chief Operating Officer
(214) 540-4454
Contract Pharmacy Representative
Elite Analytics Group, Inc
Rex Green, CEO
(469) 899-2293
Signed By Date
10/2/2020
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