Contract Pharmacy Details

AVITA PHARMACY 1029
RWII75215 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 B

340B ID

RWII75215

Entity Address

4922 Spring Ave
DALLAS, TX 75210-1359

Grant Number

X07HA00054

Participating Start Date

4/1/2013

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

4/11/2016

Contract Begin Date

7/1/2016

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 Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587

Signed By Date

4/11/2016

340B Drug Pricing Program Database