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AVITA PHARMACY 1028
STD78852 Maverick County Hospital District
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Covered Entity Details
Entity Name
Maverick County Hospital District
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78852
Entity Address
3406 Bob Rogers Dr.
STE. 210
Eagle Pass, TX 78852
Grant Number
NH25PS005182
Participating Start Date
1/1/2024
Last Recertification Date
5/15/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1028
Pharmacy Address
340B PARTNERS PHARMACY-DALLAS LLC DBA AV
750 FORT WORTH AVE STE H100
DALLAS, TX 75208-1811
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nestor Bonilla, CEO
(830) 757-4961
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
10/15/2024
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