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AVITA PHARMACY 1038
CH042430 THE COASTAL FAMILY HEALTH CENTER INC
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Covered Entity Details
Entity Name
THE COASTAL FAMILY HEALTH CENTER INC
Subdivision Name
COASTAL FAMILY HEALTH CENTER CORPORATE OFFICE
Type
HRSA-Funded Health Center
340B ID
CH042430
Entity Address
10467 Corporate Drive
Gulfport, MS 39503
Grant Number
H80CS00188
Participating Start Date
7/1/1999
Last Recertification Date
2/14/2025
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
1/7/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/16/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
ANGEL GREER, CEO
(228) 374-2494 Ext: 1133
Contract Pharmacy Representative
Avita
Shelley Gautreau, 340B Program Controller
(225) 772-1906
Signed By Date
1/7/2021
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