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AVITA PHARMACY 1039
DSH190046 TOURO INFIRMARY
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Covered Entity Details
Entity Name
TOURO INFIRMARY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190046
Entity Address
1401 FOUCHER STREET
NEW ORLEANS, LA 70115
Medicare Provider Number
190046
Participating Start Date
4/1/2006
Last Recertification Date
9/5/2024
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
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephen Matthew Baldwin, Chief Operating Officer
(504) 897-8566
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/17/2022
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