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AVITA PHARMACY 1039
STD703602 South Louisiana Medical Associates
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Covered Entity Details
Entity Name
South Louisiana Medical Associates
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD703602
Entity Address
605 Enterprise Drive Suite B
HOUMA, LA 70360
Grant Number
NH25PS005176
Participating Start Date
5/3/2022
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1039
Pharmacy Address
1631 ELYSIAN FIELDS AVE STE 200
NEW ORLEANS, LA 70117-8208
Pharmacy Comments
Contract Details
Approval Date
4/26/2022
Contract Begin Date
5/3/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wendy Rotolo, Business office manager
(985) 209-8547
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/11/2022
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