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AVITA PHARMACY 1029
RWII29201 SC HIV Council
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Covered Entity Details
Entity Name
SC HIV Council
Subdivision Name
Type
Ryan White Part B
340B ID
RWII29201
Entity Address
1813 Laurel Street
Columbia, SC 29201
Grant Number
X07HA00038
Participating Start Date
4/1/2014
Last Recertification Date
2/16/2021
Entity Termination Date
1/1/2022
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
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bambi W. Gaddist, Executive Director
(803) 309-6340
Contract Pharmacy Representative
Avita
Veleria Levy, Senior Account Executive
(704) 550-1900
Signed By Date
10/15/2014
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