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AVITA PHARMACY 1058
STD292041 Palmetto AIDS Life Support Services, Inc.
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Covered Entity Details
Entity Name
Palmetto AIDS Life Support Services, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD292041
Entity Address
2638 Two Notch Road
Suite 108
Columbia, SC 29204
Grant Number
NH25PS004378
Participating Start Date
10/1/2016
Last Recertification Date
5/7/2024
Pharmacy Details
Pharmacy Name
AVITA PHARMACY 1058
Pharmacy Address
MEDEXPRESS PHARMACY, LTD. DBA AVITA PHAR
1431 W. INNES ST.
SALISBURY, NC 28144
Pharmacy Comments
Contract Details
Approval Date
9/16/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carmen H. Julious, CEO
(803) 779-7257
Contract Pharmacy Representative
Shehan Welihindha, Account Executive
(704) 640-8354
Signed By Date
9/16/2016
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