Contract Pharmacy Details

AVITA PHARMACY 1046
CH040390 MEDLINK GEORGIA, INC.

Covered Entity Details

Entity Name

MEDLINK GEORGIA, INC.

Subdivision Name

Medlink Colbert

Type

HRSA-Funded Health Center

340B ID

CH040390

Entity Address

11 CHARLIE MORRIS RD
COLBERT, GA 30628

Grant Number

H80CS00427

Participating Start Date

7/1/2005

Last Recertification Date

2/11/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1046

Pharmacy Address

LONG'S DRUGS OF SANDERSVILLE, GEORGIA, I
2140 PEACHTREE RD NW STE 232
ATLANTA, GA 30309

Pharmacy Comments

Contract Details

Approval Date

4/12/2023

Contract Begin Date

7/1/2023

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Dave Ward, CEO
(706) 788-3234

Contract Pharmacy Representative

AVITA Pharmacy
JERRY PURCEL, Executive VP
(504) 905-4587

Signed By Date

4/12/2023

340B Drug Pricing Program Database