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AVITA PHARMACY 1039
STD71104 The Philadelphia Center
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Covered Entity Details
Entity Name
The Philadelphia Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD71104
Entity Address
2020 Centenary Blvd.
Shreveport, LA 71104
Grant Number
NH25PS005176
Participating Start Date
1/1/2014
Last Recertification Date
5/7/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1039
Pharmacy Address
1631 ELYSIAN FIELDS AVE STE 200
NEW ORLEANS, LA 70117-8208
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Alan Miciotto, Executive Director
(318) 222-6633 Ext: 2012
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/16/2023
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