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AVITA PHARMACY 1046
RWI30030 DeKalb County Board of Health
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Covered Entity Details
Entity Name
DeKalb County Board of Health
Subdivision Name
Ryan White Early Care Clinic
Type
Ryan White Part A
340B ID
RWI30030
Entity Address
445 Winn Way
Decatur, GA 30030
Grant Number
H89HA00007
Participating Start Date
10/1/2014
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
5/4/2023
Contract Begin Date
5/4/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeff Cheek, Director, Ryan White Program
(404) 612-0789
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
5/4/2023
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