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AVITA PHARMACY 1029
RWII28470 Life Changers Intervention Services LLC
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Covered Entity Details
Entity Name
Life Changers Intervention Services LLC
Subdivision Name
Type
Ryan White Part B
340B ID
RWII28470
Entity Address
5039 Main Street
Suite 2
Shallotte, NC 28470
Grant Number
X07HA00051
Participating Start Date
7/21/2022
Last Recertification Date
2/10/2025
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
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Beverly Stanley, CEO/Executive Director
(910) 754-7988
Contract Pharmacy Representative
Avita
Veleria Levy, Senior Account Executive
(704) 550-1900
Signed By Date
10/15/2014
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