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AVITA PHARMACY 1039
FQHCLA435A LIFE COAST COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
LIFE COAST COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Life Coast Community Health Center Thibodaux
Type
Health Center Program Look-Alike
340B ID
FQHCLA435A
Entity Address
1101 Audubon Ave Ste S1
Thibodaux, LA 70301-4957
Grant Number
LALCS47057
Participating Start Date
10/1/2022
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1039
Pharmacy Address
1631 ELYSIAN FIELDS AVE STE 200
NEW ORLEANS, LA 70117-8208
Pharmacy Comments
Contract Details
Approval Date
9/14/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ben Duet, CEO
(985) 492-6170
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
9/9/2022
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