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AVITA PHARMACY 1040
RWII75219 Resource Center of Dallas
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Covered Entity Details
Entity Name
Resource Center of Dallas
Subdivision Name
Type
Ryan White Part B
340B ID
RWII75219
Entity Address
2701 Reagan Street
Dallas, TX 75219
Grant Number
X07HA00054
Participating Start Date
7/1/2015
Last Recertification Date
2/10/2025
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
7/17/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marisa Elliott, Chief Operating Officer
(214) 540-4454
Contract Pharmacy Representative
Avita Drugs
JERRY PURCELL, FOUNDER
(504) 905-4587
Signed By Date
7/17/2015
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