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AVITA DRUGS ALABAMA LLC DBA AVITA PHARMA
STD361111 West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services - Wellness Center
Type
Sexually Transmitted Diseases
340B ID
STD361111
Entity Address
3050 McGehee Road
Montgomery, AL 36111
Grant Number
6NH25PS005129-05-05
Participating Start Date
6/15/2023
Last Recertification Date
5/7/2024
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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