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AVITA PHARMACY 1039
STD700725 Texas Digestive Disease Consultants
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Covered Entity Details
Entity Name
Texas Digestive Disease Consultants
Subdivision Name
Marrero
Type
Sexually Transmitted Diseases
340B ID
STD700725
Entity Address
1151 Barataria Blvd.
Suite 4400
Marrero, LA 70072
Grant Number
NH25PS005176
Participating Start Date
4/1/2024
Last Recertification Date
5/22/2024
Entity Termination Date
7/1/2025
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
3/7/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary Michael Reiss, MD
(415) 260-0370
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
1/14/2024
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