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AVITA PHARMACY 1039
STD70461 Hilton Dermatology and Aesthetics
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Covered Entity Details
Entity Name
Hilton Dermatology and Aesthetics
Subdivision Name
Hilton Dermatology and Aesthetics
Type
Sexually Transmitted Diseases
340B ID
STD70461
Entity Address
2050 Gause Blvd E, Suite 100
Slidell, LA 70461
Grant Number
NH25PS005176
Participating Start Date
4/1/2024
Last Recertification Date
5/5/2025
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
12/18/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Angel W Barrios, Office Manager
(985) 649-5880
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
1/15/2024
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