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AVITA PHARMACY 1038
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 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
10/14/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry L. Estes, Executive Director
(337) 439-5861
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
10/14/2016
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