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AVITA PHARMACY 1029
STD39216 My Brother's Keeper, Inc.
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Covered Entity Details
Entity Name
My Brother's Keeper, Inc.
Subdivision Name
Open Arms Healthcare Center
Type
Sexually Transmitted Diseases
340B ID
STD39216
Entity Address
805 E. River Place
Jackson, MS 39206
Grant Number
NU65PS923762
Participating Start Date
4/1/2014
Last Recertification Date
5/6/2025
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
7/10/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
June Gipson, CEO
(769) 216-2455
Contract Pharmacy Representative
Avita Drugs
Mark Roth, Account Manager
(504) 908-5932
Signed By Date
7/10/2014
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