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AVITA PHARMACY 1028
FQHCLA471 AIDS ARMS INC
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Covered Entity Details
Entity Name
AIDS ARMS INC
Subdivision Name
Prism Health North Texas at Worth Street Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA471
Entity Address
4004 Worth Street STE 100
Dallas, TX 75246-1638
Grant Number
LALCS53449
Participating Start Date
10/1/2024
Last Recertification Date
2/18/2025
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
10/28/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John T. Carlo, CEO
(214) 521-5191
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
10/28/2024
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