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AVITA PHARMACY 1043
RWII354011 West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services
Type
Ryan White Part B
340B ID
RWII354011
Entity Address
2703 7th Street
Tuscaloosa, AL 35401
Grant Number
X07HA00049
Participating Start Date
1/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1043
Pharmacy Address
AVITA DRUGS MISSISSIPPI LLC D/B/A AVITA
805 E RIVER PL STE A
JACKSON, MS 39202-3486
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Will Rainer, Chief Compliance Officer
(659) 734-2319
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
7/15/2024
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