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AVITA PHARMACY 1028
RWII93638 Madera County Department of Public Health
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Covered Entity Details
Entity Name
Madera County Department of Public Health
Subdivision Name
Type
Ryan White Part B
340B ID
RWII93638
Entity Address
1604 Sunrise Avenue
Madera, CA 93638
Madera, CA 93638
Grant Number
X07HA12778
Participating Start Date
1/1/2020
Last Recertification Date
2/19/2025
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
10/18/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sara Bosse, Public Health Director
(559) 675-7893
Contract Pharmacy Representative
Avita Drugs 1040
Marshall Frost, Owner
(214) 943-5187
Signed By Date
10/18/2022
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