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AVITA PHARMACY 1058
STD40206 Music City PrEP Clinic
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Covered Entity Details
Entity Name
Music City PrEP Clinic
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD40206
Entity Address
1101 E Washington St
Louisville, KY 40206
Grant Number
NH25PS005135
Participating Start Date
10/1/2021
Last Recertification Date
5/21/2024
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
9/2/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard Clark MacKinnon, Executive Director
(615) 469-1065
Contract Pharmacy Representative
Avita Drugs
Jerry Purcell, Executive Vice President
(504) 905-4587
Signed By Date
9/2/2021
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