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AVITA PHARMACY 1038
DSH190005 University Medical Center Management Corporation d/b/a University Medical Center New Orleans
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Covered Entity Details
Entity Name
University Medical Center Management Corporation d/b/a University Medical Center New Orleans
Subdivision Name
UMCNO
Type
Disproportionate Share Hospital
340B ID
DSH190005
Entity Address
2000 Canal Street
NEW ORLEANS, LA 70112
Medicare Provider Number
190005
Participating Start Date
1/1/1997
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
6/28/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/16/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Lisa Miranda, Chief Operating Officer
(504) 702-4411
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
6/28/2016
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