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AVITA PHARMACY 1029
HV26854 Southwest Louisiana AIDS Council
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Covered Entity Details
Entity Name
Southwest Louisiana AIDS Council
Subdivision Name
n/a
Type
Ryan White Part C
340B ID
HV26854
Entity Address
425 Kingsley Street
Lake Charles, LA 70601
Grant Number
H76HA26854
Participating Start Date
10/1/2014
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
8/12/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry L. Estes, Executive Director
(337) 439-5861
Contract Pharmacy Representative
Avita Drugs
Mark Roth, Account Manager
(504) 908-5932
Signed By Date
8/12/2014
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