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AVITA PHARMACY 1044
RWII354011D West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services - Dothan
Type
Ryan White Part B
340B ID
RWII354011D
Entity Address
1891 Honeysuckle Road
Suite 2
Dothan, AL 36305
Grant Number
X07HA00049
Participating Start Date
3/13/2023
Last Recertification Date
2/10/2025
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
3/13/2023
Contract Begin Date
3/14/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Billy Kirkpatrick, Chief Executive Officer
(205) 759-8470 Ext: 7
Contract Pharmacy Representative
AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587
Signed By Date
3/13/2023
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