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AVITA PHARMACY 1058
RWII29425C Medical University of SC Infectious Disease Ryan White Program
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Covered Entity Details
Entity Name
Medical University of SC Infectious Disease Ryan White Program
Subdivision Name
MUSC Ryan White Program
Type
Ryan White Part B
340B ID
RWII29425C
Entity Address
4040 Hwy 17 Bypass
Suite 306
Murrells Inlet, SC 29576
Grant Number
X07HA00038
Participating Start Date
10/1/2022
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
4/2/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard Lynn Anderson, Executive Vice President for Finance and Operations
(843) 792-5050
Contract Pharmacy Representative
Avita
Chris Creamer, COO
(469) 592-2000
Signed By Date
4/2/2025
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