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AVITA PHARMACY 1038
STD70380 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
STD70380
Entity Address
113 Picone Road
Houma, LA 70363
Grant Number
NH25PS005176
Participating Start Date
5/3/2022
Last Recertification Date
5/5/2025
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
5/3/2022
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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