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AVITA PHARMACY 1040
STD48150 Planned Parenthood of Michigan
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Covered Entity Details
Entity Name
Planned Parenthood of Michigan
Subdivision Name
Livonia Health Center
Type
Sexually Transmitted Diseases
340B ID
STD48150
Entity Address
15707 Farmington Rd
Livonia, MI 48154
Grant Number
NH25PS005170
Participating Start Date
4/1/2018
Last Recertification Date
5/5/2025
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
4/6/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Denise Thal, EVP & CFO
(734) 926-4828
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/6/2021
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