Contract Pharmacy Details

AVITA PHARMACY 1044
RWIID361301 ALABAMA DEPARTMENT OF PUBLIC HEALTH

Covered Entity Details

Entity Name

ALABAMA DEPARTMENT OF PUBLIC HEALTH

Subdivision Name

HIV AIDS DIVISION

Type

Ryan White Part B ADAP Direct Purchase

340B ID

RWIID361301

Entity Address

201 Monroe Street
Suite 1200
MONTGOMERY, AL 36104

Grant Number

X07HA00049

Participating Start Date

1/1/2004

Last Recertification Date

3/2/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1044

Pharmacy Address

AVITA DRUGS ALABAMA LLC D/B/A AVITA PHAR
3220 5TH AVE S STE 110
BIRMINGHAM, AL 35222-2309

Pharmacy Comments

Contract Details

Approval Date

1/17/2023

Contract Begin Date

1/24/2023

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Vontrese McGhee, Director, Office of HIV Prevention and Care
(334) 206-2615

Contract Pharmacy Representative

Avita Pharmacy
Keith Fox, Sr. Vice President
(225) 236-1540

Signed By Date

1/17/2023

340B Drug Pricing Program Database