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AVITA PHARMACY 1040
CHC12863-02 ST. THOMAS COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
ST. THOMAS COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Mahalia Jackson Health Service Center
Type
HRSA-Funded Health Center
340B ID
CHC12863-02
Entity Address
2405 Jackson Ave
New Orleans, LA 70113
Grant Number
H80CS12863
Participating Start Date
7/1/2014
Last Recertification Date
2/8/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1040
Pharmacy Address
AVITA DRUGS, LLC D/B/A AVITA PHARMACY 10
6100 CORPORATE BLVD STE 250
BATON ROUGE, LA 70808
Pharmacy Comments
Contract Details
Approval Date
7/11/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/21/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Donald Erwin, CEO
(504) 529-5558
Contract Pharmacy Representative
Avita Drugs
Mark Roth, Account Manager
(504) 908-5932
Signed By Date
7/11/2014
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