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AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
RWII324011 BASIC NWFL, Inc.
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Covered Entity Details
Entity Name
BASIC NWFL, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII324011
Entity Address
432 Magnolia Avenue
Panama City, FL 32401
Grant Number
X07HA00057
Participating Start Date
4/1/2023
Last Recertification Date
2/27/2025
Pharmacy Details
Pharmacy Name
AVITA DRUGS FLORIDA, LLC DBA AVITA PHARM
Pharmacy Address
1409 NE 26TH ST
WILTON MANORS, FL 33305
Pharmacy Comments
Contract Details
Approval Date
10/8/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gary Ed Cox, Executive Director
(850) 814-3195
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/8/2024
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