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AVITA PHARMACY 1028
RWII78401 Coastal Bend Wellness Foundation
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Covered Entity Details
Entity Name
Coastal Bend Wellness Foundation
Subdivision Name
Type
Ryan White Part B
340B ID
RWII78401
Entity Address
5633 S. Staples
Suite 700
Corpus Christi, TX 78414
Grant Number
X07HA00054
Participating Start Date
7/1/2013
Last Recertification Date
2/15/2016
Entity Termination Date
7/1/2016
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
1/15/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Bill Hoelscher, CEO
(361) 814-2001 Ext: 222
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
1/15/2015
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