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AVITA PHARMACY 1028
STD71104 The Philadelphia Center
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Covered Entity Details
Entity Name
The Philadelphia Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD71104
Entity Address
2020 Centenary Blvd.
Shreveport, LA 71104
Grant Number
NH25PS005176
Participating Start Date
1/1/2014
Last Recertification Date
5/7/2025
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
1/13/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brett Malone, Executive Director
(318) 222-6633 Ext: 11
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
1/13/2014
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