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AVITA PHARMACY 1040
HV12908B NO/AIDS Task Force (d.b.a. CrescentCare)
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Covered Entity Details
Entity Name
NO/AIDS Task Force (d.b.a. CrescentCare)
Subdivision Name
Family Care Services Center
Type
Ryan White Part C
340B ID
HV12908B
Entity Address
1631 ELYSIAN FIELDS AVE
New Orleans, LA 70117
Grant Number
H76HA12908
Participating Start Date
1/1/2015
Last Recertification Date
2/11/2019
Entity Termination Date
4/1/2020
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
10/17/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
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