Contract Pharmacy Details

AVITA PHARMACY 1028
RWI75215 AIDS ARMS, INC. d/b/a Prism Health North Texas

Covered Entity Details

Entity Name

AIDS ARMS, INC. d/b/a Prism Health North Texas

Subdivision Name

South Dallas Clinic

Type

Ryan White Part A

340B ID

RWI75215

Entity Address

4922 Spring Ave
DALLAS, TX 75210-1359

Grant Number

H89HA00014

Participating Start Date

1/1/2013

Last Recertification Date

2/10/2022

Entity Termination Date

10/1/2022

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

3/21/2013

Contract Begin Date

4/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/10/2020
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

John T. Carlo, CEO
(214) 521-5191

Contract Pharmacy Representative

Avita Drugs
KEITH FOX, CFO
(225) 236-1540

Signed By Date

1/15/2013

340B Drug Pricing Program Database