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AVITA PHARMACY 1028
RWII71104 PHILADELPHIA CENTER
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Covered Entity Details
Entity Name
PHILADELPHIA CENTER
Subdivision Name
Type
Ryan White Part B
340B ID
RWII71104
Entity Address
2020 CENTENARY BOULEVARD
SHREVEPORT, LA 71104
Grant Number
X07HA00018
Participating Start Date
7/1/2004
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
4/16/2012
Contract Begin Date
4/16/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brett Malone, Executive Director
(318) 222-6633 Ext: 11
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
3/28/2012
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