Contract Pharmacy Details

AVITA PHARMACY 1041
STD701608 LOUISIANA DHH OFFICE OF PUBLIC HEALTH

Covered Entity Details

Entity Name

LOUISIANA DHH OFFICE OF PUBLIC HEALTH

Subdivision Name

STD/HIV/Hepatitis Program

Type

Sexually Transmitted Diseases

340B ID

STD701608

Entity Address

1450 POYDRAS STREET
Suite 2136
NEW ORLEANS, LA 70112

Grant Number

H25PS005176

Participating Start Date

1/1/1997

Last Recertification Date

5/9/2024

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1041

Pharmacy Address

AVITA DRUGS LLC D/B/A AVITA PHARMACY 104
1715 COMMON ST STE A
LAKE CHARLES, LA 70601-6135

Pharmacy Comments

Contract Details

Approval Date

10/10/2022

Contract Begin Date

10/31/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

DeAnn Gruber, Administrative Director Louisiana OPH STD/HIV Program
(504) 568-7474

Contract Pharmacy Representative

Avita
Chris Creamer, COO
(469) 592-2000

Signed By Date

10/10/2022

340B Drug Pricing Program Database