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AVITA PHARMACY 1031
RWII79601 Dignity Health Management Center, Inc.
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Covered Entity Details
Entity Name
Dignity Health Management Center, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII79601
Entity Address
402 Butternut St.
Abilene, TX 79602
Grant Number
X07HA00054
Participating Start Date
4/28/2022
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1031
Pharmacy Address
PHARMBLUE HOLDINGS LLC D/B/A AVITA PHARM
1495 N 7TH ST STE B
BEAUMONT, TX 77702-1345
Pharmacy Comments
Contract Details
Approval Date
7/3/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Betty Sims, Executive Director
(325) 603-0691
Contract Pharmacy Representative
PharmBlue
Joseph Pohl, CEO
(724) 779-4720 Ext: 001
Signed By Date
7/3/2017
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