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AVITA PHARMACY 1029
RWII29405 Lowcountry AIDS Services
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Covered Entity Details
Entity Name
Lowcountry AIDS Services
Subdivision Name
Type
Ryan White Part B
340B ID
RWII29405
Entity Address
5064 Rivers Ave
North Charleston, SC 29406
Grant Number
X07HA00038
Participating Start Date
4/1/2013
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
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad Childs, Executive Director
(843) 747-2273
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
10/14/2014
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