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AVITA PHARMACY 1028
RW424837 AIDS ARMS, INC. d/b/a Prism Health North Texas
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Covered Entity Details
Entity Name
AIDS ARMS, INC. d/b/a Prism Health North Texas
Subdivision Name
Oak Cliff Clinic
Type
Ryan White Part D
340B ID
RW424837
Entity Address
219 SUNSET AVENUE
116A
DALLAS, TX 75208-4531
Grant Number
H12HA24837
Participating Start Date
4/1/2013
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
4/11/2016
Contract Begin Date
7/1/2016
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 Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
4/11/2016
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