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AVITA PHARMACY 1029
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
5/12/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
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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