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AVITA PHARMACY 1032
STD33142 Doctors United Group Inc
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Covered Entity Details
Entity Name
Doctors United Group Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD33142
Entity Address
1498 NW 54th Street
Suite C
Miami, FL 33142
Grant Number
NH25PS004342
Participating Start Date
7/1/2019
Last Recertification Date
5/4/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1032
Pharmacy Address
AVITA DRUGS LLC D/B/A AVITA PHARMACY 103
6260 WESTPARK DR STE 105
HOUSTON, TX 77057-7312
Pharmacy Comments
Contract Details
Approval Date
2/8/2022
Contract Begin Date
2/11/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Augustine Carbon, President
(305) 788-0007
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
2/8/2022
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