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AVITA PHARMACY 1040
RWII43201G EQUITAS HEALTH
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Covered Entity Details
Entity Name
EQUITAS HEALTH
Subdivision Name
Canton Office
Type
Ryan White Part B
340B ID
RWII43201G
Entity Address
400 TUSCARAWAS ST. W
SUITE 405
CANTON, OH 44702
Grant Number
X07HA00016
Participating Start Date
1/1/2015
Last Recertification Date
2/8/2021
Entity Termination Date
7/1/2021
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
12/10/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Avita Drugs
KEITH FOX, CFO
(225) 236-1540
Signed By Date
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