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AVITA PHARMACY 1029
DSH450213H UNIVERSITY HEALTH SYSTEM
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Covered Entity Details
Entity Name
UNIVERSITY HEALTH SYSTEM
Subdivision Name
Robert B. Green Campus FFACTS
Type
Disproportionate Share Hospital
340B ID
DSH450213H
Entity Address
903 W Martin St
San Antonio, TX 78207
Medicare Provider Number
450213
Outpatient Facility Provider Number
Participating Start Date
7/1/2004
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1029
Pharmacy Address
340B PARTNERS PHARMACY LLC D/B/A AVITA P
303 N FRIO ST
SUITE 102
SAN ANTONIO, TX 78207-3034
Pharmacy Comments
Contract Details
Approval Date
9/19/2012
Contract Begin Date
9/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MARY ANN MOTE, CHIEF REVENUE OFFICER
(210) 358-2895
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
8/31/2012
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