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AVITA PHARMACY 1041
RWII71104 PHILADELPHIA CENTER
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Covered Entity Details
Entity Name
PHILADELPHIA CENTER
Subdivision Name
Type
Ryan White Part B
340B ID
RWII71104
Entity Address
2020 CENTENARY BOULEVARD
SHREVEPORT, LA 71104
Grant Number
X07HA00018
Participating Start Date
7/1/2004
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1041
Pharmacy Address
AVITA DRUGS LLC D/B/A AVITA PHARMACY 104
1715 COMMON ST STE A
LAKE CHARLES, LA 70601-6135
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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