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AVITA PHARMACY 1038
CH06287N EXCELTH, INCORPORATED
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Covered Entity Details
Entity Name
EXCELTH, INCORPORATED
Subdivision Name
EXCELth, Inc. Dental Clinic - Algiers
Type
HRSA-Funded Health Center
340B ID
CH06287N
Entity Address
1111 Newton St
New Orleans, LA 70114-2500
Grant Number
H80CS00129
Participating Start Date
7/1/2014
Last Recertification Date
2/26/2025
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1038
Pharmacy Address
AVITA DRUGS LLC-NOLA 2 D/B/A AVITA PHARM
3308 TULANE AVE STE 102
NEW ORLEANS, LA 70119-7170
Pharmacy Comments
Contract Details
Approval Date
6/29/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHAEL A. ANDRY, CEO
(504) 524-1210 Ext: 4123
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
6/29/2016
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