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AVITA PHARMACY 1029
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 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
1/5/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cynthia Nelson, Chief Executive Officer
(210) 225-4715 Ext: 122
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
1/5/2017
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