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AVITA PHARMACY 1040
STD49660 District Health Department #10
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Covered Entity Details
Entity Name
District Health Department #10
Subdivision Name
Manistee location
Type
Sexually Transmitted Diseases
340B ID
STD49660
Entity Address
385 3rd Street
Manistee, MI 49660
Grant Number
NH25PS005170
Participating Start Date
1/1/2021
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
4/11/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sheila Parker, Clinical Supervisor
(231) 236-7588
Contract Pharmacy Representative
PMQ Group, LLC dba Avita
Chris Creamer, SVP
(469) 592-2000
Signed By Date
4/11/2025
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