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AVITA PHARMACY 1028
STD731391 ALLIANCE HEALTH FOUNDATION
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Covered Entity Details
Entity Name
ALLIANCE HEALTH FOUNDATION
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD731391
Entity Address
10317 S BROADWAY AVE
OKLAHOMA CITY, OK 73139
Grant Number
NH25PS005143
Participating Start Date
9/21/2022
Last Recertification Date
Entity Termination Date
7/1/2023
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
9/21/2022
Contract Begin Date
9/21/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
CODY TURPIN, CEO
(405) 420-7328
Contract Pharmacy Representative
Long's Drugs
Ashley Ellis, Corporate Counsel
(803) 254-5884 Ext: 42309
Signed By Date
8/18/2022
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