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AVITA PHARMACY 1040
STD48912 Planned Parenthood of Michigan
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Covered Entity Details
Entity Name
Planned Parenthood of Michigan
Subdivision Name
Lansing Health Center
Type
Sexually Transmitted Diseases
340B ID
STD48912
Entity Address
300 N Clippert St
Suite 6
Lansing, MI 48912
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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