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AVITA PHARMACY 1068
RWII79601 Dignity Health Management Center, Inc.
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Covered Entity Details
Entity Name
Dignity Health Management Center, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII79601
Entity Address
402 Butternut St.
Abilene, TX 79602
Grant Number
X07HA00054
Participating Start Date
4/28/2022
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1068
Pharmacy Address
AVITA DRUGS LLC
426 BUTTERNUT ST
ABILENE, TX 79602-1327
Pharmacy Comments
Contract Details
Approval Date
8/30/2021
Contract Begin Date
9/8/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James Austin Wagstaff, Executive Director
(325) 672-3077 Ext: 9175708015
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
8/30/2021
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