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AVITA PHARMACY 1028
RWII78208 San Antonio AIDS Foundation
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Covered Entity Details
Entity Name
San Antonio AIDS Foundation
Subdivision Name
Type
Ryan White Part B
340B ID
RWII78208
Entity Address
818 East Grayson Street
San Antonio, TX 78208-1013
Grant Number
X07HA00054
Participating Start Date
7/1/2016
Last Recertification Date
2/11/2025
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
7/12/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
David T. Ewell, Executive Director
(210) 225-4715 Ext: 122
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
7/12/2013
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