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AVITA PHARMACY 1040
RWII43214 EQUITAS HEALTH
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Covered Entity Details
Entity Name
EQUITAS HEALTH
Subdivision Name
Type
Ryan White Part B
340B ID
RWII43214
Entity Address
4400 NORTH HIGH STREET
SUITE 300
COLUMBUS, OH 43214
Grant Number
X07HA00016
Participating Start Date
1/1/2013
Last Recertification Date
2/8/2021
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
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
3/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peggy Anderson, Chief Operating Officer
(614) 340-6691
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
1/15/2013
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