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AVITA PHARMACY 1028
RWII77036 ST. HOPE FOUNDATION, INC.
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Covered Entity Details
Entity Name
ST. HOPE FOUNDATION, INC.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII77036
Entity Address
6200 SAVOY DRIVE
SUITE 540
HOUSTON, TX 77036
Grant Number
T2-TX
Participating Start Date
12/8/2005
Last Recertification Date
2/14/2020
Entity Termination Date
1/1/2021
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
6/13/2012
Contract Begin Date
6/13/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Timika Sam-Cooper, Chief Operations Officer
(713) 778-1300 Ext: 2342
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
5/29/2012
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