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AVITA PHARMACY 1040
RWII29425B Medical University of SC Infectious Disease Ryan White Program
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Covered Entity Details
Entity Name
Medical University of SC Infectious Disease Ryan White Program
Subdivision Name
MUSC Ryan White Program
Type
Ryan White Part B
340B ID
RWII29425B
Entity Address
2250 Mall Dr
North Charleston, SC 29406
Grant Number
X07HA00038
Participating Start Date
10/1/2022
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
7/26/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard Lynn Anderson, Executive Vice President for Finance and Operations
(843) 792-5050
Contract Pharmacy Representative
Avita pharmacy
Keisha Taylor, Pharmacy District Manager
(225) 924-1930
Signed By Date
7/14/2022
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