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AVITA PHARMACY 1046
FP39759 West Alabama AIDS Outreach
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Covered Entity Details
Entity Name
West Alabama AIDS Outreach
Subdivision Name
Five Horizons Health Services
Type
Family Planning (Title X only)
340B ID
FP39759
Entity Address
900 Stark Road
Starkville, MS 39759
Grant Number
FPHPA006550-01-00
Participating Start Date
1/1/2023
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1046
Pharmacy Address
LONG'S DRUGS OF SANDERSVILLE, GEORGIA, I
2140 PEACHTREE RD NW STE 232
ATLANTA, GA 30309
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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