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AVITA PHARMACY 1038
STD703603 Life Coast Community Health Center
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Covered Entity Details
Entity Name
Life Coast Community Health Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD703603
Entity Address
605 Enterprise Drive
STE C
Houma, LA 70360-5405
Grant Number
NH25PS005176
Participating Start Date
5/4/2022
Last Recertification Date
5/8/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
4/26/2022
Contract Begin Date
5/4/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ben Duet, CEO
(985) 492-6170
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/11/2022
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