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AVITA PHARMACY 1058
STD20012 Casa Ruby Inc.
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Covered Entity Details
Entity Name
Casa Ruby Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD20012
Entity Address
7530 Georgia Ave NW
Washington, DC 20012
Grant Number
NH25PS005133-02-03
Participating Start Date
8/13/2021
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
8/16/2021
Contract Begin Date
8/16/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ruby Corado, Executive Director
(202) 641-8028
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
8/16/2021
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