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AVITA PHARMACY 1047
CH043823A BREVARD HEALTH ALLIANCE INC., THE
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Covered Entity Details
Entity Name
BREVARD HEALTH ALLIANCE INC., THE
Subdivision Name
BHA Melbourne Clinic
Type
HRSA-Funded Health Center
340B ID
CH043823A
Entity Address
17 Silver Palm Avenue
Melbourne, FL 32901-3123
Grant Number
H80CS04213
Participating Start Date
4/1/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1047
Pharmacy Address
AVITA DRUGS FLORIDA LLC D/B/A AVITA PHAR
1110 KEVSTIN DR
KISSIMMEE, FL 34744
Pharmacy Comments
Contract Details
Approval Date
7/13/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Austin Helton, CEO
(321) 241-6854
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
7/13/2021
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