Contract Pharmacy Details

AVITA PHARMACY 1037
CHC28962-00 HIV/AIDS ALLIANCE FOR REGION TWO, INC.

Covered Entity Details

Entity Name

HIV/AIDS ALLIANCE FOR REGION TWO, INC.

Subdivision Name

North Blvd Clinic

Type

HRSA-Funded Health Center

340B ID

CHC28962-00

Entity Address

3801 North Blvd.
BATON ROUGE, LA 70806

Grant Number

H80CS28962

Participating Start Date

4/1/2016

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

AVITA PHARMACY 1037

Pharmacy Address

AVITA DRUGS LLC-NOLA D/B/A AVITA PHARMAC
2519 CANAL ST
NEW ORLEANS, LA 70119

Pharmacy Comments

Contract Details

Approval Date

4/8/2016

Contract Begin Date

7/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Timothy Young, Chief Executive Officer
(225) 927-1269

Contract Pharmacy Representative

Avita Drugs
KEITH FOX, CFO
(225) 236-1540

Signed By Date

4/8/2016

340B Drug Pricing Program Database