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AVITA PHARMACY 1041
STD70816 Grace House of Baton Rouge, Inc.
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Covered Entity Details
Entity Name
Grace House of Baton Rouge, Inc.
Subdivision Name
Grace Healthcare and Medical Solution Center
Type
Sexually Transmitted Diseases
340B ID
STD70816
Entity Address
9800 Airline Hwy
Suite
105
Baton Rouge, LA 70816
Grant Number
5NU62PS924522
Participating Start Date
10/1/2024
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
4/13/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ebony Brown, Chief Executive Officer
(833) 262-1101
Contract Pharmacy Representative
Grace House of Baton Rouge, Inc.
Ebony Brown, Chief Executive Officer
(833) 262-1101
Signed By Date
4/13/2025
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