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AVITA PHARMACY 1058
STD27262 Triad Health Project
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Covered Entity Details
Entity Name
Triad Health Project
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD27262
Entity Address
501 W. Westwood Avenue
High Point, NC 27262
Grant Number
6 NH25PS005152-02-01
Participating Start Date
7/1/2021
Last Recertification Date
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
5/5/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Cassity, Executive Director
(336) 275-1654
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
4/15/2021
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