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AVITA PHARMACY 1039
STD70508 Lafayette Foundation Clinic INC
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Covered Entity Details
Entity Name
Lafayette Foundation Clinic INC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD70508
Entity Address
117 Caillouet Place
Lafayette, LA 70501
Grant Number
NH25PS005176
Participating Start Date
4/1/2020
Last Recertification Date
5/5/2025
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
1/10/2023
Contract Begin Date
1/17/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Landry, Medical Director
(337) 988-9737
Contract Pharmacy Representative
Avita
Steve Sciortino, Senior Account Executive
(225) 335-4417
Signed By Date
1/10/2023
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