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AVITA PHARMACY 1029
RW424837A 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
South Dallas Clinic
Type
Ryan White Part D
340B ID
RW424837A
Entity Address
4922 Spring Ave
DALLAS, TX 75210-1359
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 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
4/5/2017
Contract Begin Date
7/1/2017
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
4/5/2017
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