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AVITA PHARMACY 1040
FQHCLA048A County of Tulare
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Covered Entity Details
Entity Name
County of Tulare
Subdivision Name
VISALIA HEALTH CENTER
Type
Health Center Program Look-Alike
340B ID
FQHCLA048A
Entity Address
2611 N Dinuba Blvd
Visalia, CA 93291
Grant Number
LALCS00070
Participating Start Date
7/1/1996
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
11/21/2022
Contract Begin Date
11/22/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Karen M Elliott, Director of Public Health
(559) 624-8481
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
11/21/2022
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