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AVITA PHARMACY 1028
CHC26587-05 SAINT HOPE FOUNDATION
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Covered Entity Details
Entity Name
SAINT HOPE FOUNDATION
Subdivision Name
St. Hope Community Health Clinic- Jersey Village
Type
HRSA-Funded Health Center
340B ID
CHC26587-05
Entity Address
20320 Northwest Fwy Ste 500
Jersey Village, TX 77065
Grant Number
H80CS26587
Participating Start Date
4/1/2022
Last Recertification Date
2/18/2025
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
5/12/2022
Contract Begin Date
5/17/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Timika Sam-Cooper, Chief Operations Officer
(713) 778-1300 Ext: 2342
Contract Pharmacy Representative
Avita
Shelley Gautreau, 340B Program Controller
(225) 772-1906
Signed By Date
5/12/2022
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