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AVITA DRUGS ALABAMA LLC DBA AVITA PHARMA
RWII354011B West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services - Selma
Type
Ryan White Part B
340B ID
RWII354011B
Entity Address
1023 Medical Center Parkway
STE 308
Selma, AL 36701
Grant Number
X07HA00049
Participating Start Date
1/1/2024
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA DRUGS ALABAMA LLC DBA AVITA PHARMA
Pharmacy Address
1891 HONEYSUCKLE RD STE 3
DOTHAN, AL 36305
Pharmacy Comments
Contract Details
Approval Date
10/14/2024
Contract Begin Date
1/1/2025
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
10/14/2024
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