Contract Pharmacy Details

AVITA PHARMACY 1029
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 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

3/14/2013

Contract Begin Date

4/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/31/2019
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