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AVITA PHARMACY 1028
DSH190054 IBERIA MEDICAL CENTER
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Covered Entity Details
Entity Name
IBERIA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190054
Entity Address
2315 EAST MAIN STREET
NEW IBERIA, LA 70560
Medicare Provider Number
190054
Participating Start Date
7/1/2004
Last Recertification Date
9/6/2024
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
4/19/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dionne E Viator, CFO
(337) 374-7107
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
4/19/2017
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