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AVITA PHARMACY 1034
STD75234 Center for Health Empowerment
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Covered Entity Details
Entity Name
Center for Health Empowerment
Subdivision Name
Center for Health Empowerment Dallas County
Type
Sexually Transmitted Diseases
340B ID
STD75234
Entity Address
951 York Drive
Ste 102
DeSoto, TX 75115
Grant Number
NH25PS005182
Participating Start Date
7/1/2019
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1034
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
2800 S IH-35 FRONTAGE RD.
STE 105
AUSTIN, TX 78704
Pharmacy Comments
Contract Details
Approval Date
5/29/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Scott Lyles, Board Chair
(512) 608-7298
Contract Pharmacy Representative
Avita
Thomas Siegmeth, acct manager
(323) 816-0525
Signed By Date
5/29/2022
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