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AVITA PHARMACY 1041
STD701163 Lafayette Foundation Clinic INC
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Covered Entity Details
Entity Name
Lafayette Foundation Clinic INC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD701163
Entity Address
914 N Rampart St
New Orleans, LA 70116
Grant Number
NH25PS005179
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1041
Pharmacy Address
AVITA DRUGS LLC D/B/A AVITA PHARMACY 104
1715 COMMON ST STE A
LAKE CHARLES, LA 70601-6135
Pharmacy Comments
Contract Details
Approval Date
1/7/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Landry, Medical Director
(337) 988-9737
Contract Pharmacy Representative
Avita
Steve Sciortino, Senior Account Executive
(225) 335-4417
Signed By Date
1/7/2025
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